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Ethnicity
Gender
Male
Female
Term for which you desire admission
Fall 20 __________
Spring 20 __________
Summer 20 __________
Do you plan to enroll:
Part-time (11 or fewer credits per semester)
Full-time (12 or more credits per semester)
Full-time students: Have you provided the required proof of immunization for measles, mumps and rubella (MMR) and hepatitis B to
Enrollment Services?
Yes
No
Full-time students: Have you provided the required proof of hospitalization insurance if not enrolling in SCC's insurance plan?
Yes
No
APPLICATION FOR ADMISSION
Please mail completed application, with $27 application fee, to:
Salem Community College
Enrollment Services
460 Hollywood Avenue
Carneys Point, NJ 08069
Information in shaded boxes MUST be completed for application to be processed. Please print clearly.
First-time application
Reapplication (for SCC graduates or students who have not attended in three or more years)
Legal Name _____________________________________________________________________________________________________________
Last First
Middle
Maiden
Mailing Name (Name by which you want to be referred in correspondence, if different than legal name)
______________________________________________________________________________________________________________________________
Last First
Middle
Maiden
Home Address
Mailing Address (Only if different from home address)
Street
Street
Apt.#
Apt.#
City
State
Zip Code
City
State
Zip Code
County of Legal Residence __________________________________ State of Legal Residence ____________________________________
Phone Numbers: Home ___________________________
Cell ____________________________ Work ______________________________
Social Security Number _____________________________________
Date of Birth _______________________________________________
E-mail Address ___________________________________________________________________________________________________________________
Emergency Contact Name ________________________________________________________________________________________________
Phone ___________________________________________________ Relationship to Student _____________________________________
856.351.2703
info@salemcc.edu
Please submit a copy of your high school transcript to Enrollment Services.
0 - Prefer not to report
1 - African-American, non-Hispanic
2 - American Indian or Alaskan Native
3 - Asian or Pacific Islander
4 - Hispanic
5 - White, non-Hispanic
6 - Mexican
7 - Puerto Rican
8 - Cuban
9 - Central or South American