Application for Admission

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1 For Admission Office Use Only ID#: Last Name: First Name: Program: Semester: Entry date: Entry clerk: Application for Admission Massachusetts Bay Community College (MassBay) is committed to an open admission policy, as defined by the Massachusetts Department of Higher Education, offering those who have earned a high school diploma, GED, associate degree, or higher degree an opportunity to enroll in a degree/certificate program. OFFICE OF ADMISSIONS Wellesley Hills Campus Framingham Campus Ashland Technology Center 50 Oakland Street 19 Flagg Drive 250 Eliot Street Wellesley Hills, MA Framingham, MA Ashland, MA Phone: TTY:

2 THREE EASY STEPS TO APPLY 1. Submit a completed application form. You may submit a completed application to: MassBay Community College Office of Admissions 50 Oakland Street Wellesley Hills, MA Or to: (Applications will not be accepted by FAX.) 2. Submit proof of high school graduation or GED/HiSET completion. Please see the Prior Education & Self Certification of Education Credentials page to determine which documents are necessary. 3. Submit Official College Transcripts (if applicable). These are required for your previous coursework to be evaluated for transfer credit. PERSONAL DATA 1. Name: First Middle Last 2. Maiden/Other Name 3. Gender: Male Female 4. Social Security Number: 5. Birth Date: (mm/dd/yyyy) 6. Country of Birth: 7. Country of Citizenship (required): USA Other: 8. Status in the U.S. (required): 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 type of visa or specify immigration status: (Please submit a copy of your visa or immigration documentation. Original documentation may be requested.) 9. Permanent Address: Apt/Unit# City/State/Zip Code: Country 10. Mailing Address (if different): Apt/Unit# City/State/Zip Code: Country 11. Preferred Phone: ( ) Home Applicant Cell Other Phone: ( ) Home Applicant Cell 12. Primary Address: *MassBay will communicate with you by , as well as by mail or phone. Please be sure to provide an address that you check regularly. Please answer both 13a and 13b 13a. Are you Hispanic/Latino? Yes No 13b. Regardless of answer to the prior question, please select one or more of the following that best describes you: American Indian or Alaskan Native (including all Original Peoples of the Americas) Asian (Far East, Southeast Asia or the Indian subcontinent and Philippines) Black or African American (including Africa and Caribbean) Native Hawaiian or Other Pacific Islander (Hawaii, Guam, Samoa or other Pacific Islands) White (including Europe, Middle East and North Africa) Other: 14. Military Status: Non-Veteran Dependent of Veteran Active Reserve Active Military Mass. National Guard Veteran ACADEMICS 15. Semester you plan to begin your program and/or pre-requisite course(s): Fall 20 Spring 20 Summer Are you planning to be: Full-time (minimum 12 credits per semester) Part-time (under 12 credits per semester) 1

3 ACADEMICS (Con t) 17. 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 HEALTH SCIENCES Nursing (Day) Nursing (Evening) Radiologic Technology (Day) Radiologic Technology (Flex) HUMANITIES General Studies (A.A.) Liberal Arts Liberal Arts: Communications SCIENCE, TECHNOLOGY, ENGINEERING & MATHEMATICS Automotive Technology: BMW Automotive Technology: Chrysler Automotive Technology: General Motors Automotive Technology: Toyota/Lexus Biotechnology Biotechnology: Forensic DNA Science Biotechnology: Marine Biotechnology Computer Information Systems Computer Science Electrical & Computer Engineering Electronics Technology Engineering Engineering Design Environmental Sciences & Safety General Studies (A.S.) General Studies: Bioinformatics General Studies: Lab Animal Care General Studies: Mathematics Information Systems Technology & Management: Management Information Systems Technology & Management: Technology Life Sciences Mechanical Engineering SOCIAL SCIENCES & PROFESSIONAL STUDIES Accounting Business Administration Criminal Justice Early Childhood Education General Business General Business: Hospitality Management General Business: International Business Liberal Arts: Community Health Option Liberal Arts: Early Childhood Education Liberal Arts: Elementary Education Liberal Arts: Human Services Liberal Arts: Global Studies Liberal Arts: Psychology/Sociology/Anthropology Paralegal Studies Certificate Programs HEALTH SCIENCES Central Processing Technology** Central Services & Material Management Emergency Medical Technician** Maxillofacial Assistant Medical Coding Medical Office Administrative Assistant Paramedicine (Day) Paramedicine (Evening) Phlebotomy** Practical Nursing (Day) Practical Nursing (Evening) Surgical Technology (Day) Surgical Technology (Evening) HUMANITIES Liberal Arts: Communications** SCIENCE, TECHNOLOGY, ENGINEERING & MATHEMATICS Automotive Technology: Toyota/Lexus Automotive Technology: TSEP I Undercarriage Repair Automotive Technology: TSEP II Drive Systems Automotive Technology: TSEP III Electrical/Engine Performance/HVAC Computer-Aided Design Cyber Security** Information Technology Technology Support** Web Designer Web Developer Web Master SOCIAL SCIENCES & PROFESSIONAL STUDIES Accounting Business: Information Technology Early Childhood Education Early Childhood Education: Infant-Toddler Teacher General Business: Entrepreneurship** General Business: Hospitality Management General Business: Marketing** High Tech Sales** Interior Design Liberal Arts: Community Health Liberal Arts: Human Services Management Paralegal Studies Undeclared** ** Not eligible for financial aid. 2 rev rar

4 PRIOR EDUCATION & SELF CERTIFICATION OF EDUCATION CREDENTIALS If you graduated from a NEASC (New England Association of Schools and Colleges) accredited high school or received your GED/HiSET certificate from a New England State, please fill out this page. It is strongly recommended that you also submit one of the documents listed below. If your educational documentation is from outside of New England, please fill out this page and submit one of the following: Official final high school transcript Copy of your high school diploma Copy of your GED/HiSET certificate Official final college transcript 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 High Education Accreditation (CHEA). Please see Qualifications and Exceptions for Self Certification of Education Credentials at the bottom of the page. 18. Please check one of the following: 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 I have earned a GED/HiSET from a New England State I have a home school diploma and I am able to submit a letter of approval from the Superintendent of Schools I graduated with a high school diploma or college degree from a US state outside of New England I have earned a GED/HiSET from a US state outside of New England I graduated with a high school diploma or College degree outside of the US I earned my Massachusetts Certificate of Attainment None of the above (please explain) 19. High School attended: Name City State Date of Graduation / / 20. GED Certificate (if applicable): (State) Issue Date / / 21. College(s) attended (if applicable): Degree earned Date of Graduation: / / Degree earned Date of Graduation: / / 22. Last school attended 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. 2. Applicants who have earned a GED/HiSET from a New England State. Applicants who have not yet earned a high school diploma or a GED will be allowed to self-certify once they have earned the high school diploma or GED/HiSET prior to registration. 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 or 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. 3

5 MASSBAY INFORMATION 23. Have you previously applied to MassBay Community College? Yes No 24. Are you: A first time college student Transferring from another college Seeking readmission to MassBay: Last semester enrolled : academic program: 25. Do you need financial aid? Yes No 26. What type of classes are you interested in taking at MassBay? Day Evening Weekend Online 27. Are you interested in joining an athletic team at MassBay? Yes No 28. Are you interested in the MassTransfer Program with the University of Massachusetts or the Massachusetts State University System? Yes No (MassTransfer is the transfer program that connects Community College students to Massachusetts State Universities and the University of Massachusetts campuses.) 29. What is your educational goal? Associate in Arts/Science Degree, then transfer to a four-year college or university Associate in Arts/Science Degree Certificate Take course(s) and transfer prior to receiving a certificate or degree Other 30. Do either or both of your parents hold an associate degree or a higher degree? Yes No INFORMATION ON FREE APPLICATION FOR FEDERAL STUDENT AID (FAFSA) Massachusetts Bay Community College awards millions of dollars in federal, state and institutional financial aid each year to eligible students. Many students, however, miss out because they do not think they are eligible and do not complete the Free Application for Federal Student Aid (FAFSA). To apply for financial aid, students must complete the FAFSA available on the Federal Financial Aid website, Financial aid can be used to pay for tuition, fees, books, transportation and other educational expenses. We strongly encourage you to complete the FAFSA. If you need help with your financial aid application or college financial planning, the MassBay Financial Aid Office has counselors who can assist you. Please select the option below that best describes your plans to complete a FAFSA. This information will have no impact on whether you are admitted to the college. I have already applied for Financial Aid I plan to apply for federal, state and institutional financial aid and am prepared to complete the FAFSA at I plan to apply for federal, state and institutional financial aid, but I need help from the Financial Aid Office to complete the FAFSA. I do not plan to apply for federal, state or institutional financial aid at this time. CERTIFICATION OF INFORMATION I certify that all information contained in this application is complete, true, and accurate. I understand that misrepresentation, falsification, or omission of information may result in the rescission of MassBay s acceptance of my admission, disciplinary action up to dismissal with no right of appeal or to a tuition refund, or loss of financial aid eligibility. I understand this application for admission will not be complete until all requirements are submitted. Signature of Applicant Date Signature of Parent or Guardian Date (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

6 MASSACHUSETTS COMMUNITY COLLEGES IN-STATE TUITION ELIGIBILITY FORM (Required to be considered for Massachusetts in-state tuition or New England Regional Rate) Last Name First Name MI Street Address City State Zip Code SSN or Student I.D. Number Date of Birth (mm/dd/yy) Are you a U.S. Citizen? Yes No If NO, are you a Permanent Resident? Yes No If you are a Permanent Resident, please provide your Alien Registration 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: 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. Valid driver s license Utility bills* Employment pay stub* Valid car registration Voter registration* State or Federal tax returns Mass. high school diploma Signed lease or rent receipt* Military home of record Record of parents residency for unemancipated person* Other I am an eligible participant in the New England Board of Higher Education Regional Student Program. 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: Date Parent/Guardian Signature: Date (if applicant is under 18) FOR OFFICIAL USE ONLY DO NOT WRITE IN THIS BOX 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: Date: 5

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

/  Framingham Campus 19 Flagg Drive Framingham, MA O17O2 5O8-27O-4OOO Country of Citizenship: College Contact Information admissions@massbay.edu / www.massbay.edu Date of Application: Wellesley Hills Campus 5O Oakland Street Wellesley Hills, MA O2481 781-239-3OOO Framingham Campus 19 Flagg Drive

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