Email: [email protected].

com
Office
Use Only Phone: Pam (402)844-7466 or Kate (402)844-7465 Fax: (402)844-7413
Date
Received
Website: northeast.edu
Use
Please TYPE or PRINT CLEARLY answers to ALL items!
only We are unable to process incomplete or illegible applications.

A. PERSONAL DATA

How did you learn about Northeast? ___________________________________________________________________________________

1. Full Legal Name _________________________________________________________________________________________________

Last/Surname First Name Middle Name Previous Last Names

2. Permanent Home Address _________________________________________________________________________________________

Number and Street/P.O. Box City State Country Postal Code

3. Student Phone (_______) ____________ May we send you a text? Yes No 4. Female Male Other

5. Birthdate _________/_________/___________ 6. Student Email__________________________________________________

Month / Day / Year

7. Country of Citizenship _________________________ 8. City and Country of Birth________________________________________

B. RACIAL/ETHNIC INFORMATION This information is optional and used only used to comply with federal guidelines, not used in determining admission

1. Without regard to your race, what is your ethnicity? 2. Without regards to your ethnicity, please select one or more racial categories:
Not Hispanic/Latino Black/African/African American Asian White
Hispanic/Latino Alaskan Native/American Indian Native Hawaiian/Pacific Islander

C. FIRST GENERATION

Are you a first-generation College Student? Yes No

D. PROGRAM OF STUDY (See a complete list on our website at northeast.edu/Degrees-and-Programs)

Please list ONE program of study: ____________________________________________________________________________________

E. APPLICATION STATUS

I am applying for the semester beginning: Fall (August)____________ Spring (January)____________

Year Year

F. CURRENT STATUS

Are you currently in the US? YES – If yes, attach a copy of passport, visa, I-94 NO

Are you currently attending school in the US? YES – If yes, attach a copy of current and previous I-20 forms issued by schools NO

Check all that apply: First-time student Transfer Student (within the United States) Current School ____________________________

G. ENGLISH PROFICIENCY

Native English Speaker – My country’s official language is English

What English proficiency testing have you taken? (Check all that apply and submit official documentation of testing scores or coursework with application)

ACT/SAT Scores TOEFL test score of 61 or higher IELTS test score of 6.5 or higher

Completion of English course at U.S. Institution (grade of “C” or higher)

 H. EDUCATIONAL BACKGROUND

Please send official copies of all academic records (with English translations, if possible)
Did you graduate from high school (secondary)? YES NO
List below, in chronological order (most recent first), every high school and college/university institution you have attended:

Institution Name ___________________________________________________________ Date of Attendance _____________to_______________

Certifications or Degrees Received ____________________________________________ Date Received (month/year) ______________________

Institution Name ___________________________________________________________ Date of Attendance _____________to_______________

Certifications or Degrees Received ____________________________________________ Date Received (month/year) ______________________

Institution Name ___________________________________________________________ Date of Attendance _____________to_______________

Certifications or Degrees Received ____________________________________________ Date Received (month/year) ______________________

I. HOUSING

Are you interested in information regarding on-campus housing? YES NO

J. FAMILY MEMBERS (F-1 VISA APPLICANTS ONLY)

If you choose to not live on campus, list other family members you are planning to live with in the U.S. while you are a student:

____________________________ _______________ __________________ _______________________________________________

Name Date of Birth Relation to you Address
____________________________ _______________ __________________ _______________________________________________
Name Date of Birth Relation to you Address

K. FINANCIAL SUPPORT (F-1 VISA APPLICANTS ONLY)

If you wish to attend Northeast Community College on an F-1 Visa, you must prove you have the resources to pay educational and living expenses
for each year of your program of study. You must provide documents that will convince the government you have:

√ Immediate Funds to cover your first year in the United States AND √ Sufficient, dependable resources to cover each additional year.
In addition to tuition and fees, you will need to pay for books, supplies, living expenses, health insurance, and travel. Indicate below your
confirmed sources of support. You MUST submit copies of your and/or your sponsor’s financial documents.

Scholarship or Grant Sponsors Your Personal Funds

Attach a copy of your award letter, √ These may be your parents, other These are your own savings and investments.
contract or letter of financial guarantee relatives, private citizens, or other organization. To prove your personal funds, you will need
You can be sponsored by more than one the following:
source. Sponsors must provide appropriate √ Bank statements that state the date the
documentation of support for you through account was opened and the current balance
affidavits and bank statements. √ Statements of liquid investments

L. EMERGENCY CONTACT (COMPLETE IN FULL)

_______________________________________________________ __________________________ ______________________________

Name Cell Phone Number Relationship to you

___________________________________________________________________________________________________________________
Number and Street Address and/or P.O. Box City State/Province Country Postal Code

M. CERTIFICATION/SIGNATURE

I certify that all information on this application is complete and accurate, and I agree to abide by the policies and regulations of
Northeast Community College
X
Signature of Applicant Date

Northeast Community College does not discriminate on the basis of race, color, gender, religion, national or ethnic origin, military veteran status, political
affiliation, marital or family status, age, disability, sexual orientation, gender expression or identity in education programs, employment policies, financial
aid or other College administered programs and activities. It is the intent of Northeast Community College to comply with both the letter and the spirit of
the law in making certain discrimination does not exist in its policies, regulations and operations. Inquiries may be addressed to the Northeast Compliance
Officer for Title X, ADA, Section 504, Associate Vice President of Human Resources, 901 East Benjamin Ave, P.O. Box 469, Norfolk, NE 68701-0469; phone:
402-844-7046; email: [email protected]; or mail: Office for Civil Rights, U.S. Department of Education, One Petticoat Lane, 1010 Walnut
Street, 3rd Floor, Suite 320, Kansas City, MO 64106