Application for Admission

STUDENT INFORMATION Social Security Number: Date of Birth:

Name (same as SS card):

Other Name/Previous Name:

Mailing Address:

City, State, Zip:

Home Phone: Cell Phone:

Email:

Employment plans while enrolled: Full Time Part Time Not employed

Did either of your parents complete a 4-year degree? Yes No

Which are you? Current High School student First time to enter college Transferring from another college Returning to ANC (MCCC)

P.O. Box 1109 Blytheville, AR 72316

Phone (870) 838-2955 Fax (870) 763-1654

Email: admissions@smail.anc.edu www.anc.edu

RESIDENCY INFORMATION Are you a legal resident of Mississippi County, AR, living in-county at least 6 months prior to this application? Yes No

If NO, please list county and state:

GENDER/ETHNICITY INFORMATION Check all that apply: Male Female

America Indian/Alaskan Native Asian Black/African American Hispanic/Latino Native Hawaiian/Pacific Islander White Other: (Voluntary information to be used in a non-discriminatory manner with application civil rights laws for reporting and statistical purposes only and cannot affect your admission eligibility.)

CITIZENSHIP What is your citizenship? U.S. Citizen

Non-Resident Alien: Country Visa Type: Expiration Date:

Resident Alien (Immigrant) Country: Card # Date Issued:

PRIOR EDUCATION/TRANSFER INFORMATION High School Graduate On-line High School Graduate GED Homeschool Graduate Did not graduate

Name of High School/GED Program: City, State Grad. Year

Previous colleges attended:

VETERAN AFFAIRS I am (a) Veteran Veteran’s Spouse Veteran’s Dependent Not requesting Veteran’s Benefits Not a Veteran

EDUCATIONAL GOALS (*1,3,4 require selection on back of this application)

(1) Earn 2 year degree for transfer to another college

(2) Take courses to transfer to another college, but not earn a degree

(3) Earn a 2 year Associate in Applied Science degree (non-transfer)

(4) Earn a Technical Certificate or Certificate of Proficiency (non-transfer)

(5) Take career/job related courses but not graduate (Solutions Group)

(6) Take course(s) for personal interest, but not graduate or earn degree

(7) Improve basic learning skills, but not graduate or earn degree

(8) Other or undecided

SELECTIVE SERVICE STATUS In compliance with Act 228 of 1997 Female

Current member of armed forces/active duty

Under 18 years of age as of application date

Over 25 years of age as of application date

Exempted resident alien (must comply with citizenship question)

Registered with Selective Service

Other

EMERGENCY CONTACT INFORMATION

Name: Phone: Relationship to student:

I certify that the information included on this application is accurate. I understand that giving false information or withholding information may make me ineligible for admission or continuation at Arkansas Northeastern College.

Signature: Date:

Office Use Only: Student ID # Notes: Rev.07.02.19

Semester you plan to attend:

Fall Spring Summer I Summer II

DEGREE/CERTIFICATE PROGRAMS If you checked 1, 3, or 4 on the Education Goals section of the application, please mark accordingly.

Associate Transfer Degrees (In-Class/Hybrid) (*1) Associate of Arts

Select a Concentration: AA – Art/Music AM – Math/Science AE – English/History/Speech AP – Psychology/Sociology/Law AH – Allied Health AU – Undecided

Associate of Science AF – Business AJ – Criminology CE – Childhood Education (Mid-level 4-8)Select a Concentration for CE Major: K-6 Math/Science Art/Math Math/Social Studies Art/Science Science/Social Studies Art/Social Studies

Associate of General Studies Select a Concentration: GP – Pre-Allied Health GM – Mathematics/Sciences GA – Fine Arts/Perf. Arts GC – Computer Technologies GH – Humanities/Social Sci. GK – Music

Associate Transfer Degrees (Online) (*1) IA – Associate of Arts IB – Associate of Science – Business IC – Associate of Science – Criminology IE – Associate of Science – Childhood EducationSelect a Concentration for IE major: K-6 Math/Science Art/Math Math/Social Studies Art/Science Science/Social Studies Art/Social Studies

Online Associate of Applied Science Degrees (*3) IJ – Criminal Justice IS – Steel Industry Technology

Associate of Applied Science (*3) 14 – Advanced Manufacturing Technology 22 – Air Conditioning & Refrigeration 04 – Aviation Maintenance 05 – Computer Information Systems 17 – Criminal Justice 20 – Early Childhood Education 26 – Nursing (RN) 10 – Office Management 13 – Steel Industry Technology 24 – Welding

Technical Certificate (*4) 57 – Administrative Support 52 – Air Conditioning & Refrigeration 51 – Aviation Maintenance 61 – Dental Assisting 62 – Paramedic 60 – Practical Nursing (LPN) 55 – Welding

Certificate (*4) 65 – General Studies

Certificate of Proficiency (*4) 72 – Advanced Manufacturing 75 – Air Conditioning & Refrigeration 91 – Child Development Associate (CDA) 70 – Clerical Support 81 – Construction Technology 83 – Criminal Justice 94 – Emergency Medical Technician (EMT) 74 – General Aviation 69 – General Industrial Technology 76 – Industrial Electrical Systems 95 – Nursing Assistant (CNA) 99 – Phlebotomy 79 – Welding

To complete your application, please submit the following:

♦ Official high school transcript or GED Test Scores (if you have never attended another college/university)♦ Official college transcript(s) for all other colleges/universities you have attended♦ Placement test scores—ACT or ACCUPLACER♦ Immunization Records—students must have 2 doses of the MMR vaccine (excludes ONLINE ONLY degrees/certificates)

For Disability Services, contact Blythe Gillen at (870) 838-2955.

For Title IX & Affirmative Action issues, contact Jim McClain, VP for Student Affairs/Information Technology P.O. Box 1109, Blytheville, AR 72316 or by calling (870) 762-1020