New Hampshire Community Technical College / Laconia
379 Belmont Road
Laconia, NH 03246

Telephone (603) 524-3207     Fax (603) 524-8084

in N.E. call 1-800-357-2992


Application for Admission


Personal Data

Name (First, Middle, Last)

__________________________________________________________________

List other names used on school records

__________________________________________________________________

Social Security Number ______-_______-________

Mailing Address

__________________________________________________________________

City__________________________________ State_______ Zip_____________

Country_____________________

E-mail Address_______________________________________      U.S. Citizen    Yes____ No____

Telephone:    Home (_____) ______________ Work (_____) ______________    Ext._______

(Optional)    Male ______    Female _____    Date of Birth _____/_____/_______

Services

If you would like to receive printed information on services for students with disabilities,
please contact the Learning & Career Center at 800-357-2992

Are you eligible for National Guard Educational Assistance Programs?    Yes____    No____

Veterans

Are you eligible for Veterans Educational Benefits?    Yes____    No____

Are you applying for Survivors' & Dependents' of Veterans Educational Assistance?    Yes____    No____


PROGRAM / MAJOR INFORMATION

Program Choice: ____________________________________________

Check One:    Degree ______    Diploma _______    Certificate_______

Which semester do you wish to begin your studies?    Fall _____    Spring _____    Year _____

I am applying to:    Day ______    Comm. Education (evening) ______    Full-time ______    Part-time ______

Have you ever applied to this institution?    Yes _____    No _____    (If Yes) Date:    Month______    Year _____

Have you ever attended this institution?    Yes _____    No _____    (If Yes) Date:    Month______    Year _____


HIGH SCHOOL INFORMATION

High School C.E.E.B. Code _______________________

School Name __________________________________

Address ______________________________________

City _________________________    State ________    Zip _____________

High School Graduation Date _____/_____/_____    OR Year G.E.D. Awarded _____/_____/_____


COLLEGE(S) PREVIOUSLY ATTENDED

School Name __________________________________

City ___________________________    State ________

Dates Attended____________________    Degree______________


EMERGENCY CONTACT

Name (First, Middle, Last)

__________________________________________________________________

Check One:    Parent_____    Spouse _____    Other_____

Address__________________________________________________________

City__________________________________ State_______ Zip_____________

Telephone:    Home (_____) ______________ Work (_____) ______________    Ext._______


PROOF OF RESIDENCE

In-state-Applicants

You must complete one of the statements regarding domicile. If neither is appropriate, attach a notarized
statement detailing all the facts upon which your claim for NH domicile is based. If you are claiming NH
domicile but are not currently living in the state, be certain to explain the circumstances which require that
you live elsewhere. Payment of property taxes does not in itself constitute the basis for a claim to a legal
domicile. A copy of rules governing tuition rates mat be obtained by writing to the Admissions Office.
Misrepresentation of facts in order to establish a claim to a NH domicile will be viewed by the Admissions
Office as a justification for revoking an acceptance or returning an application without consideration.

Years of residence in NH. _________

If you are financially dependent on or are living with your parents, fill out the following

Students Name (First, Middle, Last)

__________________________________________________________________

Legal domicile:

Street____________________________________________________________

City__________________________________ State_______ Zip_____________

The parents of the above named applicant have been legally domiciled at the address above for the past twelve months.
The family has no other domicile.

Signature of Parent _________________________________________________


If you are not living with your parents and are financially independent, fill out the following

Students Name (First, Middle, Last)

__________________________________________________________________

Legal domicile:

Street____________________________________________________________

City__________________________________ State_______ Zip_____________

I have been legally domiciled at the above address for the past twelve months. I have no other domicile,
I am on the checklist of the town or city of domicile, and I am financially independent.

Signature of Student ________________________________________________


OUT-OF-STATE APPLICANTS

New England Regional Student Program (NERSP)

The New England Regional Student Program enables a resident of a New England state to enroll in
a public college or university in the six-state region at reduced rates for certain degree programs.
NERSP applies if the program is not available in a home state public institution, or the
out-of-state public institution is nearer to the student's residence than the in-state institution that offers
a similar program.

For New England residents who wish to be considered for NERSP

I am a resident of: City__________________________________ State_______ Zip_____________
and request to be considered for NERSP

I am applying for: (Specify Major) _____________________________________

Signature of Student ________________________________________________


TO BE SIGNED BY ALL APPLICANTS

The information provided by the applicant on this admission application form shall be held confidential
to the extent determined by Federal law and college policy. New Hampshire Community Technical College
reserves the right to deny admission to any applicant who, in the judgement of college officials, does not
qualify for admission. The College also reserves the right to require withdrawal of any student who does
not satisfy the ideals of citizenship, character, or scholarship.

Upon acceptance, I agree to abide by the rules and regulations, terms, and conditions set forth in all
publications. I also agree that the College has permission to use any college-sponsored pictures in which
my likeness appears. I certify that I have read and agree with the above, and that all information provided
herein is true and complete.

Signature of Student ________________________________________________    Date_________


Signature Parent/Legal Guardian (if student is under 18 years)

________________________________________________________________    Date_________


FOR OFFICE USE

Action ___________________________________

Residency    IS    OS    NERSP


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