/ Framingham Campus 19 Flagg Drive Framingham, MA O17O2 5O8-27O-4OOO Country of Citizenship:

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1 College Contact Information / Date of Application: Wellesley Hills Campus 5O Oakland Street Wellesley Hills, MA O OOO Framingham Campus 19 Flagg Drive Framingham, MA O17O2 5O8-27O-4OOO Ashland Automotive Technology Center 25O Eliot Street Ashland, MA O O3O *When application is complete, please mail to Wellesley Hills Campus, Admissions Office. Biographical Information: Name: First: Middle: Last: Maiden / Other Name: Social Security Number (Only required if applying for financial aid): Date of Birth: (mm/dd/yyyy): Country of Birth: Country of Citizenship: USA OTHER: (Please Specify) Status in the U.S.: Native (U.S. Citizen) Naturalized (U.S. Citizen) Permanent Resident: USCIS # (Please submit a copy of your Permanent Resident Card. Original documentation may be requested.) If not a U.S. Citizen or Permanent Resident, list current type of visa or specify immigration status: (Please submit a copy of your visa or immigration documentation. Original documentation may be requested.) Contact Information: Permanent Address: Apt/Unit #: Country: Mailing Address (if different): Apt/Unit #: Country: Home Phone: Cell Phone: Primary Address: Optional Information: Gender: o Male o Female Are you Hispanic/Latino? o o Regardless of answer to the prior question, please select one or more of the following that best describes you: o American Indian or Alaskan Native (including all Original Peoples of the Americas) o Asian (Far East, Southeast Asia or the Indian subcontinent and Philippines) o Black or African American (including Africa and Caribbean) o Native Hawaiian or Other Pacific Islander (Hawaii, Guam, Samoa or other Pacific Islands) o White (including Europe, Middle East and rth Africa) o Other: Military Status: o t a Veteran o Military Reserve o Active Military o Mass. National Guard o Veteran 1 October 2015

2 Enrollment Plan: Semester you plan to begin your program and/or pre-requisite course: Spring 2016: Summer 2016: Fall 2016: Have you previously applied to MassBay Community College?: Are you: A first time college student Transferring from another college Seeking readmission to MassBay: Last semester enrolled: Academic Program: Intended Major: Are you planning to be: Full-time (Minimum 12 credits per semester) Part-time (Under 12 credits per semester) Check the ONE program in which you are interested. Programs in italics have special admission requirements. All applicants to programs in italics will be first placed into General Studies Health or General Studies Automotive. Consideration is based upon completion of admissions requirements and space availability. Associate Degree Programs: o Accounting o Automotive Technology: BMW o Automotive Technology: Chrysler o Automotive Technology: General Motors o Automotive Technology: Toyota/Lexus o Biotechnology o Biotechnology: Forensic DNA Science o Biotechnology: Marine Biotechnology o Business Administration o Computer Information Systems o Computer Science o Criminal Justice o Early Childhood Education o Electrical & Computer Engineering o Electronics Technology o Engineering o Engineering Design o Environmental Sciences & Safety o General Business o General Business: Hospitality Management o General Business: International Business o General Studies (A.A.) o General Studies (A.S.) o General Studies: Bioinformatics o General Studies: Mathematics o Information Systems Technology & Management: Management o Information Systems Technology & Management: Technology o Liberal Arts o Liberal Arts: Communications o Liberal Arts: Community Health Option o Liberal Arts: Early Childhood Education o Liberal Arts: Elementary Education o Liberal Arts: English o Liberal Arts: Global Studies o Liberal Arts: Human Services o Liberal Arts: Psychology/Sociology o Life Sciences o Mechanical Engineering o Nursing (Day) o Paralegal Studies o Radiologic Technology (Day) o Radiologic Technology (Flex) Certificate Programs: o Accounting o Advanced Cyber Security** o Automotive Technology: Toyota/Lexus o Automotive Technology: TSEP I Undercarriage Repair o Automotive Technology: TSEP II Drive Systems o Automotive Technology: TSEP III Electrical/Engine Performance/HVAC o Business: Information Technology o Central Processing Technology** o Computer-Aided Design o Cyber Security** o Early Childhood Education o Early Childhood Education: Infant-Toddler Teacher o Emergency Medical Technician** o General Business: Entrepreneurship o General Business: Hospitality Management o General Business: Marketing o High Tech Sales o Information Technology o Interior Design o Liberal Arts: Communications** o Liberal Arts: Community Health** o Liberal Arts: Human Services o Management o Manufacturing Innovation** o Manufacturing Technology** o Medical Coding o Medical Office Administrative Assistant o Paralegal Studies o Paramedicine (Day) o Paramedicine (Evening) o Phlebotomy** o Practical Nursing (Day) o Surgical Technology (Day) o Surgical Technology (Evening) o Technology Support o Undeclared** o Web Designer o Web Developer o Web Master ** t eligible for financial aid. 2

3 Qualifications for Self-Certification of Education Credentials: 1. Applicants who have graduated from a New England Association of Schools and Colleges, Inc. (NEASC) accredited high school with a high school diploma or a College/University with a degree. It is strongly recommended that you submit proof of graduation, GED or equivalent. 2. Applicants who have earned a GED/HiSET from a New England State. Exceptions to Self-Certification of Education Credentials 1. All Health Science and Automotive Technology programs require proof of final education credential to be considered for acceptance. Applicants should carefully review specific admission requirements for their program of interest. 2. International Applicants seeking an F-1 visa are required to submit proof of final education credentials. 3. Educational documents from schools outside of New England must be submitted. All international documents must be translated into English and evaluated into United States standards by a certified credentials agency. Self-Certification of Education Credentials: Please fill out the section below to be considered for self-certification. If your educational documentation is from outside of New England, please submit one of the following items below. Schools outside of New England must be accredited by an accreditation agency recognized by the US Department of Education (USDE) or by the Council for Higher Education Accreditation (CHEA). o Official final high school transcript o Copy of your high school diploma o Copy of your GED/HiSET certificate o Official final college transcript Please check one of the following: o I graduated with a high school diploma* or college degree from a New England State (Applicants who graduated from a Massachusetts public high school since 2003 must have successfully completed all MCAS requirements) o I have earned a GED/HiSET from a New England State o I have a home school diploma and I am able to submit a letter of approval from the Superintendent of Schools o I graduated with a high school diploma or college degree from a US state outside of New England o I have earned a GED/HiSET from a US state outside of New England o I graduated with a high school diploma or College degree outside of the US o I earned my Massachusetts Certificate of Attainment o ne of the above (please explain) Please fill out your high school and college information if applicable. Please check off which school you last attended or are currently attending. High School attended: Date of Graduation: GED Certificate (if applicable): Issue College(s) attended (if applicable): Degree earned: Date of Graduation: Degree earned: Date of Graduation: 3

4 MassBay Information: Are you interested in joining an athletic team at MassBay?: What is your educational goal?: o Associate in Arts/Science Degree, then transfer to a four-year college or university o Associate in Arts/Science Degree o Certificate o Take course(s) and transfer prior to receiving a certificate or degree Are you interested in the MassTransfer Program with the University of Massachusetts or the Massachusetts State University System? (MassTransfer is the transfer program that connects Community College students to Massachusetts State Universities and the University of Massachusetts campuses.) Are you interested in an accelerated 1 year Associates degree program?: Are you currently unemployed?: Do either or both of your parents hold an associate degree or a higher degree?: Are you planning to apply for financial aid?: o I already completed & submitted FAFSA for this year o I plan to apply for financial aid and I need help completing FAFSA o I do NOT plan on submitting my FAFSA For more information about financial aid opportunities, please visit our website massbay.edu/financialaid. Is English your first language?: How did you first hear about MassBay Community College?: o Friend or Family Member o MassBay Faculty or Staff Member o Guidance Counselor o College Fair or School Visit o Drove by Campus o MassBay Website o Online College Search Tools (collegeboard, naviance, zinch/chegg, cappex, etc.) o A Community Based Organization o Social Media o Newspaper o Radio or TV o Direct Mail Certification of Information: I certify that this information is true and accurate. I understand that any misrepresentation, omission or incorrect information shall be cause for disciplinary action up to dismissal, with no right of appeal or to a tuition refund. Applicant Signature: Parent/Guardian Signature (If applicant is under 18): Massachusetts Bay Community College does not discriminate on the basis of race, color, national origin, sex, sexual orientation, age, or disability, in admission or access to or treatment or employment in its programs and activities. Any inquiries or complaints concerning compliance with the regulations implementing Title IV, Title VII, Title IX, Age Discrimination Act of 1975, or Section 504 may contact the Director of Human Resources at Inquiries may also be directed to the Assistant Secretary for Civil Rights, U.S. Dept. of Education, Washington, D.C., 20202, or the Director, U.S. Dept. of Education, Office for Civil Rights, Region One, Boston, MA THE COLLEGE RESERVES THE RIGHT TO ADD, WITHDRAW OR REVISE ANY PROVISION OR REQUIREMENT DESCRIBED ON THIS FORM. The Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act requires colleges and universities to publish an annual security report. The report contains information regarding campus security including such topics as: emergency procedures, crime prevention, law enforcement authority, crime reporting policies, sexual assault prevention, disciplinary procedures and other matters of importance related to security on campus. It also contains crime statistics for the previous three calendar years. You can find MassBay Community College s crime statistics online at To request a printed copy Jeanne Clery Disclosure report, please call , or stop by the Public Safety Office. 4

5 MASSACHUSETTS COMMUNITY COLLEGES IN-STATE TUITION ELIGIBILITY FORM (Required to be considered for Massachusetts in-state tuition or New England Regional Rate) Name: First: Middle: Last: Street Address: SSN or Student I.D. Number: Date of Birth (mm/dd/yyyy): Are you a U.S. Citizen?: If no, are you a Permanent Resident? If you are a Permanent Resident, please provide your USCIS Number: If you are not a U.S. Citizen or Permanent Resident, please specify your current visa or immigration status: Please check the in-state or reduced tuition eligibility category that applies to you: o I have been a Massachusetts resident for six (6) continuous months and intend to remain here indefinitely. As proof of my intent to remain in Massachusetts, I possess at least two of the following documents, which I shall present to the institution upon request. These documents* are dated within one year of the start date of the academic semester for which I seek to enroll (except possibly for my high school diploma). The institution reserves the right to make any additional inquiries regarding the applicant s status and to require submission of any additional documentation it deems necessary. Please check at least two of the documents you possess as proof of your intent to remain in Massachusetts. o Valid driver s license o Valid car registration o Mass. high school diploma o Record of parents residency for unemancipated person* o Utility bills* o Voter registration* o Signed lease or rent receipt* o Employment pay stub* o State or Federal tax returns o Military home of record o Other o I am an eligible participant in the New England Board of Higher Education Regional Student Program. o I am a member of the armed forces (or spouse or unemancipated child) on active duty in Massachusetts. Certification of Information: I certify that this information is true and accurate. I understand that any misrepresentation, omission or incorrect information shall be cause for disciplinary action up to dismissal, with no right of appeal or to a tuition refund. Applicant Signature: Parent/Guardian Signature (If applicant is under 18): FOR OFFICIAL USE ONLY - DO NOT WRITE UNDER THIS LINE I have reviewed the above information in order to determine this individual s eligibility to receive the in-state tuition rate. Based on my review I have determined that this individual: [ ] IS eligible for the in-state tuition rate. [ ] IS NOT eligible for the in-state tuition rate. [ ] I am unable to make a determination at this time. The following additional information has been requested from the applicant: Authorized College Personnel: 5