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Personal Information |
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First Name |
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Last Name |
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Middle Name |
(Enter NMN for None) |
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Date of Birth |
-- mm/dd/yy |
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Sex |
Male
Female |
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SSN Number |
(International enter 111-11-1111) |
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Race?
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Marital Status?
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Are you a Veteran? |
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If yes, do you
plan to use VEAP? |
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Were you referred
by an agency? |
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Are you a US
Citizen? |
If
No |
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Are you a Kansas
Resident? |
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Local Contact Information |
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Street address |
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Address
(cont.) |
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City |
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State/Province |
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Zip/Postal
code |
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Work Phone |
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Home Phone |
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E-mail |
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Legal Address
(Leave Blank if same) |
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Street address |
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Address
(cont.) |
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City |
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State/Province |
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Zip/Postal
code |
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Country |
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Phone |
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Legal county of
residence? |
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Date of Kansas
residency? |
-- mm/dd/yy |
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In
Case of Emergency Contact Person |
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Name |
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Street address |
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Address
(cont.) |
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City |
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State/Province |
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Zip/Postal
code |
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Country |
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Work Phone |
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Home Phone |
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FAX |
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E-mail |
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Education History |
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What Semester do you plan
to enter ICC? |
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What year do you plan to
enter ICC? |
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Student Classification? |
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Are you currently in High
School? |
If Yes |
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Did you graduate from High
School? |
If No |
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Year of Graduation? |
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Name
of High School and Location?
Jump to next Question |
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GED Information |
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If no, have you taken the
GED? |
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Location?.
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Date you took the GED?
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-- mm/dd/yy |
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List All Prior Colleges |
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International Student Information |
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Visa type |
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Country of Birth |
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INS Admission number |
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Country of citizenship |
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Resident Alien A# |
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Resident Alien Date |
-- mm/dd/yy |
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Country of Origin |
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Date Moved to Kansas |
-- mm/dd/yy |
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County living in |
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Degree Plans |
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Are you seeking a degree? |
*
If No |
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What type of degree are you
seeking |
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Select your major area or select areas of
interest if undecided on your major |
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Where
did you find out about ICC? |
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What are your Educational Objectives? |
Transfer to another college/university
Enter job market
Personal/self improvement
Improve skills for present job
Improve basic Skills
Prepare for a job change
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The following information is used to monitor
compliance with several federal and state
statutes. You are not obligated to respond,
and if you do, your response will not affect
your admission. |
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Does either parent have
a bachelors degree? |
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Are you or will you be
receiving financial aid? |
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Approximate family
income |
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Have you attended any
other colleges? |
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Form Complete!
All finished! Click on Submit below to
validate the form. If any errors are found,
you will be told where the error is, and in
some browsers taken to the location. After
correcting the error, click on submit again
to repeat the process. If for some reason
you are unable to submit the form, print it
and mail it to: Independence Community
College, Attention: Admissions, PO Box 708,
Independence, KS 67301 or fax the completed
form to 1 (620) 331-0946
By clicking "Submit Form" below, I certify
that all the information is complete and
correct.
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