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Note: This form is only for students not seeking a degree from Quinsigamond Community College. Complete the form, then click the Submit button. All fields with * must be completed.

  

SSN # or QCC ID# 

Prefix

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First

Middle

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Last

Suffix

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Address 1

Address 2

*

City

*

State

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ZIP code

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Home Phone

Cell Phone

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Date of Birth

*

Email Address

*

Sex

Are you a veteran of the U.S. Armed Forces ?


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Race/Ethnicity-Select as many as apply






Are you Hispanic/Latino ?


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Are you a United States citizen ? If yes, go to section DOCUMENTATION.

 

Are you a Permanent Resident ?


If yes, list Alien Registration Number

If you are not a U.S. Citizen or Permanent Resident, please state your Visa or immigration status in detail including Home Country.

DOCUMENTATION If you are a US citizen or permanent resident, select A or B or C.

A.

I have been a Massachusetts resident for six (6) continuous months and intend to remain here. As proof of my intent to remain in Massachusetts, I possess at least 2 of the following documents, which I shall present to the institution upon request. These documents are dated within one (1) year of the start date of the academic semester for which I seek to enroll (except possibly for my high school diploma). The institution reserves the right to make any additional inquires regarding the applicant's status and to require submission of any additional documentation it deems necessary.

  

Please check-off those documents you possess as proof of your intent to remain in Massachusetts











B. I am a member of the armed forces (or spouse or unemancipated child) on active duty in Massachusetts


C. I am not a Massachusetts resident. My home state is :

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What Semester are you registering for

Example: ENG 101, 01, Composition I, 3

  

   Course 1

  
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Course Code

*

Section #

*

Course Title

   Credits

   Course 2

  

   Course Code

   Section #

    Course Title

   Credits

   Course 3

  

   Course Code

   Section #

   Course Title

   Credits

   Course 4

  

   Course Code   

  Section #

   Course Title

   Credits

 
  

Prerequisites will be strictly adhered to. If you have taken the required prerequisite course(s) at another institution for the above selection(s), please UPLOAD a copy of unofficial transcript.

  
  
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I certify that this information is true and accurate. I understand that any misrepresentation, omission or incorrect information shall be cause for disciplinary action up to dismissal, with no right of appeal or to a tuition refund.

Type in your First and Last Name as an electronic signature
 

*

Date:

Parent/Guardian Signature (Student is under 18 years old)