Wellesley Hills Campus 5O Oakland Street Wellesley Hills, MA O2481 781-239-3OOO

Please mail completed application to Wellesley Hills Campus, Office of Admissions, or fax to 781-239-2508.

Framingham Campus 19 Flagg Drive Framingham, MA O17O2 5O8-27O-4OOO

Ashland Automotive Technology Center 25O Eliot Street Ashland, MA O1721-2389781-239-3O3O

College Contact Information admissions@massbay.edu / www.massbay.edu

Date of Application:

Preferred First Name (for use on non-legal documents such as class rosters):

Social Security Number (required if applying for financial aid):

Biographical Information:

Legal Name: First: Middle:

Maiden / Other Name:

Country of Birth: Country of Citizenship: USA

Native (U.S. Citizen) Naturalized (U.S. Citizen) Permanent Resident: USCIS #(Important: Be sure to provide your USCIS number and submit a copy of your

Permanent Resident Card. Original documentation may be requested.)

OTHER: (Please Specify)

Last:

Date of Birth: (mm/dd/yyyy):

If not a U.S. Citizen or Permanent Resident, list current type of visa or specify immigration status:Important: Please submit a copy of your visa or immigration documentation or DACA card. Original documentation may be requested.

Apt/Unit #:

Apt/Unit #:

Contact Information:

Permanent Address:

City:

Mailing Address (if different):

City:

Home Phone:

Primary E-Mail Address:

Cell Phone:

State:

State:

Zip Code:

Zip Code:

Country:

Country:

Optional Information: o Maleo Femaleo I choose not to disclose

Are you Hispanic/Latino? o Yeso No

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 North Africa)o Other:

Military Status: o Not a Veteran o Military Reserve o Active Military o Mass. National Guard o Veteran

1 November 2017

Status in the U.S.:As an undocumented applicant, you have the option to choose "Native (U.S. Citizen)". This option is considered a valid response and we recommend this choice for undocumented applicants, including those with DACA status.

Enrollment Plan:

MassBay Community College Admissions Application

Intended Major:

Semester you plan to begin your program and/or pre-requisite course:

Are you planning to be:

o Automotive Technology: BMWo Automotive Technology: Chryslero Automotive Technology: General Motorso Automotive Technology: Toyota/Lexus

o Automotive Technology: Toyota/Lexuso Automotive Technology: TSEP I Undercarriage Repairo Automotive Technology: TSEP II Drive Systemso Automotive Technology: TSEP III Electrical/Engine/HVAC

Emergency Medical Technician**o

Paramedicine (Day)oParamedicine (Evening)oPhlebotomy**

Practical Nursing (Day)o Surgical Technology (Day)o Surgical Technology

(Evening)

o

o

Nursing (Day)Radiologic Technology (Day) Radiologic Technology (Flex)

Spring 2018

Are you: A first time college student

Full-time (Minimum 12 credits per semester) Part-time (Under 12 credits per semester)

Transferring from another college Seeking readmission to MassBay:Last semester enrolled: Academic Program:

Have you previously applied to MassBay Community College?: Yes No

2

Check the ONE major in which you are interested.

Selective Admissions Programs:Selective Admissions Programs have special admissions requirements. All applicants to these programs will be first placed into General Studies. Once program prerequisites are met, applicants may be considered for admission into the selective program. Information on the selective process will be provided upon admission to General Studies.Associate Degree Programs:

Certificate Programs:

Associate Degree Programs:

Certificate Programs:

** Not eligible for financial aid.

Central Processing Technology**

o Accountingo Advanced Cyber Security**o Computer-Aided Designo Cyber Security**o Early Childhood Educationo Early Childhood Education: Infant-Toddler Teachero General Business: Entrepreneurshipo General Business: Hospitality Managemento General Business: Marketingo Information Technologyo Interior Design

Liberal Arts: Communications** o Liberal Arts: Human Serviceso Managemento Manufacturing Innovation**o Manufacturing Technology**o Medical Codingo Medical Office Administrative Assistanto Paralegal Studieso Technology Supporto Web Designero Web Developero Web Master

EngineeringEngineering DesignEnvironmental Sciences & Safety General General BusinessGeneral Business: Hospitality Management General Business: International Business General Studies (A.A.)General Studies (A.S.)General Studies: Mathematics Information Systems Technology & Management: ManagementInformation Systems Technology & Management: Technology

Liberal ArtsLiberal Arts: CommunicationsLiberal Arts: Early Childhood Education Liberal Arts: Elementary Education Liberal Arts: EnglishLiberal Arts: Global StudiesLiberal Arts: Human ServicesLiberal Arts: Psychology/Sociology Life SciencesMechanical EngineeringParalegal Studies

AccountingBiotechnologyBiotechnology: Forensic DNA Science Biotechnology: Marine Biotechnology Business AdministrationComputer Information Systems Computer ScienceCriminal JusticeCyber SecurityEarly Childhood Education Electrical & Computer Engineering

o Automotive Technology: BMWo Automotive Technology: Chryslero Automotive Technology: General Motorso Automotive Technology: Toyota/Lexus

o Automotive Technology: Toyota/Lexuso Automotive Technology: TSEP I Undercarriage Repairo Automotive Technology: TSEP II Drive Systemso Automotive Technology: TSEP III Electrical/Engine/HVAC

Emergency Medical Technician**Paramedicine (Day)Paramedicine (Evening)

Phlebotomy**Practical Nursing (Day) Surgical Technology (Day) Surgical Technology (Evening)

Nursing (Day)Radiologic Technology (Day)Radiologic Technology (Flex)

Selective Admissions Program Intention Declaration:Selective Admissions Programs have special admissions requirements. If you are interested in one of these programs, please select your major (above) as General Studies (A.S.) and indicate your intent to pursue admission to a selective program by indicating your interest below . Once program prerequisites are met, applicants may be considered for admission into the selective program. Information on the selective process will be provided upon admission to General Studies (A.S.) Please plan to meet with an Admissions Counselor to review program-specific admission requirements.

Associate Degree Programs:

Certificate Programs:

Fall 2018 Summer 2018

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 diplomao 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 Massachusettspublic high school since 2003 must have successfully completed all MCAS requirements)o I have earned a GED/HiSET from a New England Stateo I have a home school diploma and I am able to submit a letter of approval from the Superintendent of Schoolso I graduated with a high school diploma or college degree from a US state outside of New Englando I have earned a GED/HiSET from a US state outside of New Englando I graduated with a high school diploma or College degree outside of the USo I earned my Massachusetts Certificate of Attainmento None 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: If outside New England be sure to submit an official transcript or a copy of your diploma, verified* if from outside U.S. Name:

Degree earned:

Name:

City:

Degree earned:

GED Certificate (if applicable): State: Issue Date:

City: State: Date of Graduation:

Date of Graduation:

Date of Graduation:

/ /

/ /

/ /

mm dd yyyy

mm dd yyyy

mm dd yyyy

mm dd yyyy/ /

1. Applicants who have graduated from a New England Association of Schools and Colleges, Inc. (NEASC) accredited high school with ahigh school diploma or a College/University with a degree. It is strongly recommended that you submit proof of graduation, GEDor 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 intoEnglish and evaluated into United States standards by a certified credentials agency.

Qualifications for Self-Certification of Education Credentials:

3

MassBay Community College Admissions Application

o

o

o

College (s) attended (if applicable): If seeking transfer credit be sure to submit official transcripts, verified* by a certified agency if non-U.S.

Name:

City: State:

State:

* Important: All international education documents must be evaluated by an independent agency such as WES or CED.

MassBay Information:Are you interested in joining an athletic team at MassBay?:

Are you currently unemployed?: Yes No

Do either or both of your parents hold an associate degree or a higher degree?:

Are you planning to apply for financial aid?:

How did you first hear about MassBay Community College?:

Is English your first language?:

I already completed & submitted a Free Application for Federal Student Aid (FAFSA) for this yearI plan to apply for financial aid I do NOT plan on submitting a FAFSA

For more information about financial aid opportunities, please visit our website massbay.edu/financialaid and fafsa.gov.

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 781-239-3171. 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 02109.

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 www.massbay.edu/police. To request a printed copy Jeanne Clery Disclosure report, please call 781-239-2699, or stop by the Public Safety Office.

o Friend or Family Membero MassBay Faculty or Staff Membero Guidance Counseloro College Fair or School Visito Drove by Campuso MassBay Websiteo Online College Search Tools (collegeboard, naviance, zinch/chegg, cappex, etc.)o A Community Based Organizationo Social Mediao Newspapero Radio or TVo Direct Mail

What is your educational goal?: o Associate in Arts/Science Degree, then transfer to a four-year college or universityo Associate in Arts/Science Degreeo Certificateo 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 University of Massachusetts campuses?

Yes

Yes

Yes

Yes

No

No

No

No

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):

Date:

Date:

4

MassBay Community College Admissions Application

Yes No

MASSACHUSETTS COMMUNITY COLLEGES IN-STATE TUITION ELIGIBILITY FORM (Required to be considered for Massachusetts in-state tuition or New England Regional Rate)

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.

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.

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:

Applicant Signature:

Authorized College Personnel:

Date:

Date:

Valid driver’s licenseValid car registration!Mass. high school diploma Record of parents’ residency for unemancipated person* Utility bills*

Voter registration*Signed lease or rent receipt* Employment pay stub* State or Federal tax returns Military home of record Other________________

Name: First:

Street Address:

City:

SSN or Student I.D. Number:

Are you a U.S. Citizen?:

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:

Date of Birth (mm/dd/yyyy):

State: Zip Code:

Middle: Last:

Yes No If no, are you a Permanent Resident? Yes No

Parent/Guardian Signature (If applicant is under 18): Date:

5

MassBay Community College Admissions Application