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New International Student Supplemental Application Form

This application form is for new International students seeking Admission to Clinton Community College.

Family Name: *

Middle Name:

First Name *

Gender: *

Date of Birth: (MM DD YYYY) *

Country of Birth: *

Foreign Address: Must be outside of United States. Type exactly as it should appear in English on an envelope. *

Country Code: *

City Code: *

Number: *

Email address (preferred method of communication): *

Do you currently hold any immigration status in the United States? *

If yes, please indicate your visa type:

Have you ever been convicted of a felony (a crime for which more than one year of prison may have been imposed)? *

Have you ever been dismissed from a college or university for disciplinary reasons? *

Is this your first time enrolling in a college or university? *

Have you been enrolled or are you currently enrolled in a college or university? *

Is English your native language (the language spoken in your home)? *

If no, what is your native language?

What is the language of instruction in your high school? *

Country of Citizenship *

Have you taken an English proficiency exam, such as the TOEFL or IELTS? (These exams are not required for Admission) *

Father's family (last) name: *

Father's first (given) name: *

Mother's family (last) name: *

Mother's first (given) name: *

Parent or Guardian's email address: *

Is anyone helping you with the application process? *

If yes, please indicate the advisor's name and title (for example: Mr. Smith, School Counselor):

Advisor's Phone Number Country Code:

City Code:


Advisor's email address:

Educational Data:

Please list all secondary schools and universities attended: *

Secondary Schools (High School): Grade Level *

Secondary Schools (High School): Years Attended *

Secondary Schools (High School): Name of School *

Secondary Schools (High School): Location: City & Country *

Secondary Schools (High School): Diploma Type *

College or University: Grade Level

College or University: Years Attended

College or University: Name of School

College or University: Location: City & Country

College or University: Diploma Type

Can you provide documentation of your immunization health records? *

Semester of Study *

Domestic Mailing Address: (Optional)

Program of Study:

Please submit the completed application form. A member of our staff will be contacting you soon to discuss your application status and to discuss additional steps.