EXCELSIOR COMMUNITY COLLEGE Updated□ Scanned □

STUDENT APPLICATION FORM Receipt No.:

START DATE: □ SEPTEMBER __________
□ JANUARY ___________
PLEASE READ CAREFULLY BEFORE COMPLETING THIS FORM.
(NB. YOU SHOULD WRITE CLEARLY IN INK USING BLOCK CAPITALS.)
PERSONAL DATA
1. FIRST NAME 2. MIDDLE NAME (S)

3. SURNAME 4. MAIDEN SURNAME [Family name at birth]

5. AGE 6. DATE OF BIRTH 7. MARITAL STATUS - Tick the appropriate box:

Single Divorced 8. GENDER M F

DD MM YY Married Widowed
9. NATIONALITY: 12. RELIGION:
10. COUNTRY OF BIRTH: 13. DENOMINATION:
11. NATIVE LANGUAGE:
14a. TAX REGISTRATION NUMBER (TRN): 14b. PATH: NO □ YES □ PATH#
CONTACT INFORMATION
15. PERMANENT ADDRESS 16. TELEPHONE NUMBERS
NUMBER & STREET NAME (DISTRICT) HOME:

WORK:
NUMBER & STREET NAME (DISTRICT) LINE 2
CELL:

TOWN/CITY/PARISH 17. E-MAIL ADDRESS

COUNTRY

18. ADDRESS WHILE AT COLLEGE (If different from above) 19. TELEPHONE NUMBERS
NUMBER & STREET NAME (DISTRICT) HOME:

WORK:
NUMBER & STREET NAME (DISTRICT) LINE 2
CELL:

TOWN/CITY/PARISH COUNTRY

EMERGENCY CONTACT
20. FIRST NAME 21. SURNAME

22. RELATIONSHIP 24. TELEPHONE NUMBERS

HOME:

23. ADDRESS WORK:

NUMBER & STREET NAME (DISTRICT)
CELL:
NUMBER & STREET NAME (DISTRICT) LINE 2 25. E-MAIL ADDRESS

TOWN/CITY/PARISH COUNTRY

PROGRAMME
26. PROGRAMME TO WHICH APPLICATION IS MADE: 27a. MODE OF STUDY:
Programme 1st Option: Day

Programme 2nd Option: Evening

Mountain View Week-End
28. CAMPUS: Deanery Road Camp Road
Eureka Road St. Thomas (Wesley Grove) Modular
Month(s)
29. Intended length of stay at this Institution: Year(s) ✔ 27b. PREFFERED DELIVERY MODE
Yes [ ] No [ ]
30. Were you previously a student at this College? Face-to-face Hybrid
If YES: School/Faculty: Online
Programme:
Year Started: I.D. No.:

F-R/11 Student Application Form V.5.0 Revised October, 2021

 ACADEMIC RECORD
31. EDUCATIONAL EXPERIENCE:(LIST THE NAMES OF THE INSTITUTIONS YOU HAVE ATTENDED)
DATE (S) :
INSTITUTION(S) : TYPE/LEVEL
From To PROGRAMME/COURSE
OF AWARD
Mth. Year Mth. Year

32. ACADEMIC RECORD:

NOTE: ALL DOCUMENTS SUBMITTED TO THE ENROLMENT OFFICE BECOME THE PROPERTY OF EXCELSIOR COMMUNITY COLLEGE
AND WILL NOT BE RETURNED TO APPLICANT OR FORWARDED TO ANOTHER INSTITUTION.

RESULTS KNOWN RESULTS AWAITING

SUBJECT(S) /CERTIFICATES LEVEL(S) (eg. YEAR GRADE SUBJECT(S) LEVEL(S) YEAR

CSEC, CAPE, (eg. CSEC,
Certificate) CAPE,
Certificate)

33. CO-CURRICULAR ACTIVITIES OF INTEREST:

34. ACHIEVEMENTS:

35. INTENDED CAREER:

36. DO YOU HAVE ANY PHYSICAL DISABILITIES? Yes No If Yes, please SPECIFY

SOURCE OF FUNDING
36.
SELF
PARENT NATIONAL YOUTH SERVICE
STUDENTS’ LOAN BUREAU (SLB)
PATH
PRIVATE LOAN □
JAMVAT
SCHOLARSHIP: SPECIFY
OTHER (PLEASE SPECIFY)
SPONSOR:
 PRIVATE: SPECIFY

 GOVERNMENT:SPECIFY
37. ARE YOU AN ECC STAFF MEMBER? Yes No

38. ARE YOU A DEPENDENT OF AN ECC STAFF MEMBER? Yes No STATE RELATIONSHIP:

F-R/11 Student Application Form V. 5.0 Revised October 2021

 FOR PARENTS/GUARDIAN/NEXT OF KIN
39. THIS CERTIFIES THAT I AM PARTIALLY / WHOLLY RESPONSIBLE FOR
WHILE HE/SHE IS ATTENDING THE COLLEGE AND WILL BE FINANCIALLY RESPONSIBLE FOR HIS/HER EXPENSES.

PRINT NAME RELATIONSHIP SIGNATURE DATE

ADDITIONAL INFORMATION
40. WORK EXPERIENCE:

EMPLOYED TO: COMPANY’S NAME:

 PUBLIC SECTOR
YEARS EMPLOYED TO THE COMPANY:
 PRIVATESECTOR
POSITION HELD:
 SELF EMPLOYED

41. FUTURE PLANS:

PLEASE SELECT YOUR EDUCATIONAL GOAL(S):
 CERTIFICATE PROGRAMME  OBTAIN KNOWLEDGE FOR PERSONAL INTEREST
 ASSOCIATE DEGREE PROGRAMME  TRAIN FOR NEW CAREER BY TAKING SELECTED COURSES
 BACHELOR’S DEGREE PROGRAMMME  UPGRADE SKILLS FOR CURRENT JOB

42. HOW DID YOU OBTAIN INFORMATION ABOUT ECC?

RADIO ADVERTISEMENT INTERNET EMPLOYEE OF ECC CAMPUS VISIT

TELEVISION FAMILY ALUMNI
NEWSPAPER FRIEND CURRENT STUDENT OTHER _

SOCIAL MEDIA PLEASE SPECIFY

DECLARATION
I HEREBY CERTIFY THAT THE INFORMATION GIVEN ABOVE IS TRUE.

APPLICANT’S SIGNATURE DATE

THIS FORM IS TO BE COMPLETED AND RETURNED TO THE ENROLMENT OFFICE

ALONG WITH DOCUMENTS LISTED BELOW.

FOR OFFICE USE ONLY

RECEIVED
 ORIGINAL & ONE (1) COPY OF EXAMINATION RESULTS
 ORIGINAL & ONE (1) COPY OF BIRTH CERTIFICATE
 ORIGINAL & ONE (1) COPY OF DEED POLL (WHERE APPLICABLE)

 TWO (2) RECENT PASSPORT SIZE PICTURES (NAME, DEPARTMENT & YEAR WRITTEN ON BACK)
 ONE CHARACTER REFERENCE LETTER (FROM THE LAST SCHOOL ATTENDED OR CURRENT EMPLOYER OR
MINISTER OF RELIGION OR JUSTICE OF THE PEACE)
 ORIGINAL & ONE (1) COPY OF TAXPAYER REGISTRATION NUMBER (TRN)
 ORIGINAL & ONE (1) COPY OF MARRIAGE CERTIFICATE (WHERE APPLICABLE)
 TWO (2) REFERENCE FORMS FOR NURSING (FROM THE LAST SCHOOL ATTENDED OR CURRENT EMPLOYER OR
MINISTER OF RELIGION OR JUSTICE OF THE PEACE)
 APPLICATION FEE _ (NB.APPLICATION FEE IS NON-REFUNDABLE)

Enrolment Officer Date

F-R/11 Student Application Form V. 5.0 Revised October 2021

 FOR OFFICIAL USE ONLY

K-13 YES NO
PATHWAYS: ONE TWO THREE

TYPE OF ACCEPTANCE

□ FULL ACCEPTANCE

□ CONDITIONAL ACCEPTANCE

□ MATURE ENTRY

SUMMARY OF QUALIFICATIONS:
………………………..…………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………

RECOMMENDATIONS…………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………

I agree to meet the full requirements for matriculation before the start of the next academic year.

APPLICANT’S NAME [PRINT NAME] SIGNATURE DATE

COMMENTS…………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………

EVALUATED BY [PRINT NAME] SIGNATURE DATE

REGISTRAR’S SIGNATURE (WHERE APPLICABLE) DATE

_

F-R/11 Student Application Form [Type text] V. 5.0 Revised October 2021