Alpena Community College - Student Application


Application for Admission



Items in bold type are required.
Name
	Last Name	First Name	Middle Initial	Suffix	Maiden Name
	(Please provide full legal name-for identification purposes only.)
Address
	Street Address	City	State/Province	Zip Code	County

Country
Phone
	Cell Phone	Home Phone
Social Security Number (Format: 999999999)
Gender	MaleFemale	Date of Birth
Ethnic Hispanic/Latino	YesNo
Race (choose one or more)	American/Alaskan NativeBlack or African AmericanWhite AsianHawaiian/Pacific IslanderUnknown
Email Address
Start Term
Program of Study

Campus Location	Alpena Main CampusOff Campus SiteWorld Center for Concrete Tech Huron Shores CampusOn Line CourseOther

Admission Status	Dual EnrollmentInternationalReadmitTransfer Out-Of-State GuestNew First Time StudentTransfer In-State
Citizenship	U.S. CitizenResident AlienNon-Resident Alien
Language	EnglishFrenchGermanItalianSpanishOther
Marital Status	SingleMarriedDivorcedWidowedSeparated
Residency	In-District (Alpena Public School District)In-State (Michigan) Service District (Presque Isle, Montmorency, Alcona, and Iosco counties)Out of State
Are you or have you ever been a member of the U.S. Military? YesNo
Are you the spouse/dependent of a U.S. Veteran? YesNo
Emergency Contact Person		SpouseParent/GuardianChildOther
Emergency Contact Phone Number
Last High School Attended		City State
Graduated from High School?	High School DiplomaGED CertificateHome SchooledCertificate of CompletionNone of the above
Years of High School Attendance		Years Attended to
Transfer Information: If you have attended another college or university, complete the information below and have all official college transcripts sent directly to the Registrar's Office, Alpena Community College, 665 Johnson Street, Alpena, MI 49707-1495.
College Degree			Years Attended to
College Degree			Years Attended to
The information on this application is accurate. I understand that providing false information could lead to disciplinary action.
Alpena Community College Institutional Statement of Non-discrimination For any publication that is related to any activity, service or program that utilizes federal funds: Alpena Community College policies and practices for admission, employment and activities comply with requirements of Title VII of the Civil Rights Act of 1964, Title IX of the Education Amendment of 1972 as amended, Section 504 of the Rehabilitation Act of 1973 as amended, the Age Discrimination in Employment Act of 1967 (ADEA), the Americans with Disability Act (ADA) of 1990, the ADA Amendments Act of 2010, Title II of the Genetic Information Nondiscrimination Act of 2008. The College does not discriminate on the basis of race, color, religion, national origin, gender, sex, age, or disability. The College practices and policies also comply with the Michigan Persons with Disabilities Civil Rights Act (PDCRA) and the Michigan Elliott-Larson Civil Rights Act (ELCRA) which prohibits discrimination in hiring based on age, height, weight and marital status and familial status in addition to race, color, religion, sex (which includes pregnancy) and national origin. For more information, contact the Title IX, Section 504, the Age Discrimination Act and the Title II coordinator: Carolyn Daoust, Title IX Coordinator/Director of Human Resources Office: ACC, Room VLH102 Phone: (989) 358-7211 Email: daoustc@alpenacc.edu Alpena Community College publishes an Annual Security Report and Annual Fire Safety Report to comply with the Jeanne Clery Disclosure of Campus Security Policy and Crime Statistics Act, as amended. In compliance with federal law, the College notifies all prospective students and employees of how to locate this information. The full text of this report can be located on the ACC website at: http://discover.alpenacc.edu/acc_asr.pdf Paper copies of the report can be obtained at Van Lare Hall Room 110 or by calling (989)358-7235.
You must acknowledge that you read the above information before submitting your application