Your Information

Social Security Number:    Semester*:  Summer 2008 Fall 2008 Spring 2009  

Campus*:  Main Columbus Technical Campus Coffeyville Technical Campus

Last Name*:   First Name*: Middle Name:

Maiden Name:   E-mail Address:   

Legal Home/Permanent Street Address*:
City*:   State*: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip Code*:

Sex: Female Male    Date of Birth (MM/DD/YYYY): / /

Home Phone Number*:         Cell/Mobile Phone Number:

Residency Information

Are you a resident of Kansas?* Yes No  (If you answered yes, answer the following 2 questions).
Date Kansas Residency Began? (MM/DD/YYYY) / /
In what Kansas county do you reside?

Demographic Information

This section is optional and is requested for local, state and federal reporting purposes only.

Ethnicity:
African American/Black  American Indian or Alaska Native   Asian   Pacific Islander
White   Hispanic   Other

Are you a United States veteran?  Yes  No

Did either parent attend college?  Yes  No

Academic Information

Have you graduated from high school or received a GED certificate?  Yes  No
If yes, complete the following: When did you graduate?  (MM/YYYY) /
High School or GED Center graduated from:  
City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Are you currently attending high school or working toward a GED?  Yes   No
If yes, complete the following: When will you graduate?  (MM/YYYY)  /
High School or GED Center graduated from:  
City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Have you attended any other colleges, universities, or vocational technical schools? Yes  No
If yes, complete the following:

Are you planning to enroll? Full-time  Part-time
What course of study or college major are you pursuing? 

Why are you enrolling at Coffeyville Community College? (Check only box below)

Citizenship Information

• Are you a United States citizen*?  Yes No
• If no, give country of birth:
• Country of Citizenship: 
• Alien Registration Number:
• Type of Visa: Permanent Resident  Student (F-1)   Other

Other Background Information

Have you completed the ACT/SAT assessment?  Yes  No
If yes, have you provided the scores to CCC?  Yes  No
Do you plan to apply for on-campus housing?  Yes  No
Emergency Contact Person:   Relationship: 
Street:   City:   State:  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:
Home Telephone:    Work Phone:

Application Process

College policy requires that any graduate from an accredited high school must have an official copy of their transcript with graduation date on file and/or GED scores plus any transcript from a college, university, institution previously attended forwarded to: Registrar's Office, Coffeyville Community College, 400 West 11th, Coffeyville, KS  67337.  

Please mark the following:

Yes  No  -  I certify that the information in this application is complete and correct. 

Yes  No  -  I further understand that submission of false information is grounds for denial of admission or immediate suspension if enrolled. 

Yes  No  -  If accepted as a student at CCC, I agree to abide by the rules and regulations of the college regarding conduct and other obligations.

Coffeyville Community College is committed to a policy of educational equity.  Accordingly, the College admits students, grants, financial aid and scholarships, conducts all educational program activities and employment practices without regard to race, color, religion, sex, national origin, age, marital status, ancestry or disabilities.  Coffeyville Community College is an Equal Opportunity Institution. 

  (After pressing the submit button, please be patient for the form to be processed.  This process may take a minute or two.  Once the form is processed, you will be directed to a thank you page).