Please enter the necessary information for ALL items that apply to you to speed your application. Items in purple are required to process your admission.

Personal Information:

Today's Date

Social Security #

Last Name:

First Name: (legal)

First Name: (preferred)

Middle:

Birth Name: (if different from above)

Last name/other name on your previous academic transcripts

Permanent address:

Number/street City

State Zip

Country

Current address: (if different)

Number/street: City

State/Country: Zip

Contact Information:

Parent Information:

Parent/Guardian: (if student is under age 21)

Parent's Address:

Number/street City

State/Country Zip:

Of your parent(s), which one has the most education? Please select one Mother Father

Please indicate level of education: Please select one Less than 12th grade 12th grade SomeCollege 4 year college graduate Post graduate Dont Know

Ethnic Information: (Optional) Please select one African-American/Black Caucasian/White Asian/Pacific Islander American Indian/Alaskan Native Hispanic (Latino) Other

Gender: Please select one Male Female

Birth date:

Residency Information:

Are you a U.S. Citizen? Please select one Yes No

If no, are you a permanent resident of the U.S.? Please select one Yes No

If no, indicate type of Visa:

If yes, print your alien registration number:

Country of citizenship, if you are not a U.S. citizen:

Iowa Residency Statement:

I have been a resident of Iowa since birth.

I have been a permanent resident of Iowa since (month and year)

I am a resident of (state)

Admission Information:

At which location will you attend classes? Please select one Iowa Falls Marshalltown Online Grinnell

Term Beginning: Please select one August (Fall) December (Winter Interim) January (Spring Semester) May Interim June (1st Summer Term) July (2nd Summer Term)

Student Status: Please select one Full Time (12 credits or more) Part-Time (Less than 12 credits)

Degree and Major:

What are your educational plans? (Check any that apply)

Enrolling for Summer Classes only

Taking one class only

Degree Information:

Degree you're planning to seek (Please select only one degree. If you cannot find the exact match for your interest, select the closest one. You will be able to change later if you change your mind or your circumstances.)

Choose one only in this section.... Accounting Agriculture Art Athletic Training Business Administration Business Education Communication/PR/Journalism Computer Science Construction Management eCommerce&WebPage Development Education (Elementary) Education (Secondary) Education (Special) Engineering English Family & Consumer Science Fire Science Health, Physical Ed & Recreation Health Services Administration History Horiculture Human Services Industrial Education (Teaching) Law Liberal Arts Management Information Systems/MIS Medicine Mortuary Science Music Nursing (BSN) Pharmacy Physical Therapy Political Science Psychology Science Sociology Social Work Veterinary Medicine Wildlife/Fisheries/Forestry Accounting Agricultural Science Biotechnology Business Administration Conservation Technology Criminal Justice (Law Enforcement) Criminal Justice (Corrections) Laboratory Technology Marketing Ag Science/Agribusiness Ag Science/Farm Management Construction Technology Construction Retail Equine Management Fashion Merchandising Merchandising and Retail Management Nursing, Associate Degree (RN) Office Careers/Administrative Assistant Accounting Practitioner Ag Science Ag Science/Agricultural Practitioner Ag Science/Swine Management Biotechnology Practitioner Business/Small Business Practitioner Computer Application Specialist Computer Science Practitioner Construction Technology Commercial Practitioner Construction Technology Masonry Construction Technology Residential Practitioner Equine Practitioner Microsoft Office Practitioner Nursing, practical (LPN) Office Practitoner

Educational Information:

Did you graduate from high school? Please select one Yes No Year

High school attended City/State

Are you currently in high school? Please select one Yes No

Are you Home Schooled? Please select one Yes No

Have you taken the GED? Please select one Yes No Year

Please have your high school transcript or or GED scores mailed directly to us from the school. Faxed transcripts or transcripts issued to students are NOT considered official. This is not required for those taking only one ECC class.

List all other colleges/universities you've attended. (Remember to contact each school and ask that an official transcript be sent to ECC as soon as possible.)

What Award/Degree did you receive at your previous college?

Certificate

Associate Degree

Masters Degree

Does Not Apply

Diploma

Bachelors Degree

Doctoral Degree

Why did you choose to enroll at ECC?

Disabilities, if any (optional)

Students with disabilities should, as early as possible, contact the Associate Dean of Developmental Services at (641) 648-4611 or toll-free at 1-800-ECC-9235, ext. 459, to request assistance and coordination of accommodations.

ECC offers joint admission with selected four-year institutions. If you plan to continue your education after ECC, to what college/university will you transfer?

ECC Activities Interest Indicator (Check one or more):

I hereby certify that the information given in this application is true and correct.

Name Date

Certification Verification: Type the words "I Certify" in the box at right to confirm:

Educational Equity Policy Statement

It is the policy of the Iowa Valley Community College District to provide equal educational and employment opportunities without discriminating on the basis of race, religion, color, creed, marital status, national origin, age, disability, sexual orientation, or gender, in its educational programs, activities or its employment and personnel policies.

The institution shall provide program activities, a curriculum and instructional resources which will reflect the racial and cultural diversity present in the United States and the variety of careers, roles, and lifestyles open to both men and women in our society. The curriculum, programs, and services shall foster respect and appreciation for the cultural diversity found in our country and an awareness of the rights, duties, and responsibilities of each individual as a member of a pluralistic society.

It is the policy of the Iowa Valley Community College District to affirmatively recruit women and men, members of diverse racial/ethnic groups, and persons with disabilities for job categories where they are under represented. A fair and supportive environment will be provided for all students and employees regardless of their race, religion, color, creed, marital status, national origin, age, disability, sexual orientation or gender. Harassment of a sexual nature or with demeaning intent related to any legally protected characteristic, made from one employee to another, from an employee to a student or vice versa, and from one student to another is a violation of this policy.

Employees or applicants who feel that they have been discriminated against may file a formal complaint through the District Complaint Procedure. Grievance forms may be obtained from the Director of Human Resources, the Dean of the College at either Ellsworth or Marshalltown Community College or the Iowa Valley Continuing Education administrative office.

Inquiries or grievances related to this policy may be directed to: Margi Boord, Equity Officer, Iowa Valley Community College District, 3702 S. Center Street, Marshalltown, IA 50158, (641) 752-4643, ext. 335; the Director of the Iowa Civil Rights Commission in Des Moines (515) 281-4121; the Director of the Region VII Office of the United States Equal Employment Opportunity Commission; or the Director of the Region VII Office of Civil Rights, United States Department in Kansas City, Missouri (816) 880-4200.