Jenzabar University

Records Office ♦ 3835 Green Pond Road ♦ Bethlehem, PA 18020 ♦ Fax: 610-861-5551

RE-ADMIT FORM
To be used by students who did not attend for one or more major semesters or who previously applied but never attended.

Student ID# or last 4-digits of Social Security #:                 Birth date:

Last Name:  First Name:   Middle Initial:

Prior Name:
Note: Name changes require a marriage certificate, court order or divorce decree showing the change.

Cell Phone #:

Alternate Phone #:   Extension:

I understand that Northampton Community College may use an automated calling system and a pre-recorded message to contact me by phone at any phone number I provide to the College.

(No P.O. Box only, must provide street location)

Permanent Address:

                      City:     State:     ZipCode:
                        

Mailing Address:    

                City:     State:     ZipCode:

County of Residence:     Resident School District:

Changing your permanent address may affect your Residency status.  Review the Residency Policy:
        http://catalog.northampton.edu/residency-policy.htm

   Gender: Male    Female

   Are you Hispanic? Yes    No

Re-Admit semester: Select Semester Fall Winter Spring Summer         Re-Admit year: Select Year

Intended Program/Major upon return: Select Major

Semester last attended: Select Semester Fall Winter Spring Summer         Last attended year:

            I applied previously, but never attended  Yes  No

            Program/Major during last attendance:

Have you ever received a degree, certificate, or specialized diploma from NCC? No Yes

Have you attended any other college/university since your last attendance at NCC? No Yes

        If yes, list other college/university:
        *For transfer credits to be evaluated, submit official transcripts from all other colleges/universities to
           transcripts@northampton.edu and complete a "Request for Transfer Credit Evaulation" form.

Have you graduated from any other college/university since your last attendance at NCC?  No Yes

        If yes, indicate college/university:   

                 Indicate degrees received:

Are you a US Military Veteran*, Active Duty Service Member or Guradsman/Reservist? (*one who has been discharged/released from service under conditions other than dishonorable) No Yes

        If yes, which branch?   

Are you the spouse or dependent child of a US Military Veteran* or Active Duty Service Member? (*one who has been discharged/released from service under conditions other than dishonorable) No Yes

Processing Note: A student who did not indicate veteran or active duty status at the time of application may provide documentation (i.e. DD214 form) to the Office of Student Veterans Services to have the College database records updated.