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ReEntry Form

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

Returning Semester *
 Fall 2015
 Spring 2016

First Name *

Last Name *

If you previously attended under a different last name, please list former name:

Street Address: *

City: *

State: *

Zip Code: *

Contact Phone Number: *

Last four digits of social security number: *

Email Address: *

Were you academically dismissed the last semester you attended? *

If yes, have you completed the Academic Appeals process and received permission to re-enroll? The appeal form can be completed on line at:

Since leaving Clinton, have you attended any other college or university? *

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? *

Since leaving Clinton, have you been dismissed from another college for disciplinary reasons? *

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.

What degree program to you intend to enroll: *

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.