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ReEntry Form

Completed by student who previously attended but has stopped out one or more semesters.


Was the last semester you attended, prior to fall 2003? *
 Yes
 No


Returning Semester *
 Spring 2015
 Fall 2015


First Name *


Last Name *


If you previously attended under a different last name, please list former name:


Street Address: *


City: *


State: *


Zip Code: *


Contact Phone Number: *


Last four digits of social security number: *


Email Address: *


Were you academically dismissed the last semester you attended? *
 Yes
 No


If yes, have you completed the Academic Appeals process and received permission to re-enroll? The appeal form can be completed on line at: http://www.clinton.edu/StudentServices/readmissionform.fml
 Yes
 No


Since leaving Clinton, have you attended any other college or university? *
 Yes
 No


If yes, please list any colleges that you have attended, including online colleges, since leaving CCC. Students are required to forward all transcripts from additional colleges attended to the CCC Admissions Office.


Since leaving Clinton, have you been convicted of a felony? *
 Yes
 No


Since leaving Clinton, have you been dismissed from another college for disciplinary reasons? *
 Yes
 No



An affirmative response to the previous two questions will not automatically prevent re-entry, but applicants will be asked to provide additional information to be reviewed by the Admissions Review Committee to determine eligibilty to register for classes.



By clicking submit, I certify that the information on this form is correct. False information or omission of data may result in denial of re-entry, financial aid, or dismissal.