Clinton Community College

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ReEntry Form

Completed by student who previously attended but has stopped out one or more semesters.

Returning Semester: *
Spring
Fall
Summer

Year: *

Name: *

Street Address: *

City: *

State: *

Zip Code: *

Contact Phone Number: *

Last four digits of social security number: *

Were you academically dismissed the last semester you attended? *
Yes
No

If yes, have you completed the Academic Appeals process and received permission to re-enroll? The appeal form can be completed on line at: http://www.clinton.edu/StudentServices/readmissionform.fml
Yes
No

Since leaving Clinton, have you attended any other college or university? *
Yes
No

If yes, please list any colleges that you have attended, including online colleges, since leaving CCC. Students are required to forward all transcripts from additional colleges attended to the CCC Admissions Office.

Since leaving Clinton, have you been convicted of a felony? *
Yes
No

Since leaving Clinton, have you been dismissed from another college for disciplinary reasons? *
Yes
No

An affirmative response to the previous two questions will not automatically prevent re-entry, but applicants will be asked to provide additional information to be reviewed by the Admissions Review Committee to determine eligibilty to register for classes.

By clicking submit, I certify that the information on this form is correct. False information or omission of data may result in denial of re-entry, financial aid, or dismissal.