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Your Social Security Number is used to coordinate the collection of information for all your student records. Authority to collect the Social Security Number is granted under Section 355 of the New York Education Law. *

Instructions

  • Complete all the required information below.
  • Press "Reset" to correct your application.
  • Press "Send" to submit your application.

Personal Information

First Name MI Last Name
Date of Birth     Former Name
SS #     Email
Home Phone ( )     Cell Phone ( )

Mailing Address

My mailing address is the same as my permanent address.
 
Address City
State Zip
County Country

Permanent Address (P.O. Box is not an acceptable address)
 
Address City
State Zip
County Country

Please Indicate Your Location and Semester

Ammerman Campus   Eastern Campus   Grant Campus   Sayville Downtown Center
Fall      Winter      Spring      Summer

Please Indicate Your Status

NY State resident for prior 12 months Yes   No   U.S. Citizen Yes   No
Suffolk County resident for prior 6 months Yes   No   Veteran Yes   No
Will you be attending SCCC while attending high school? Yes   No
Have you ever been suspended from college for disciplinary reasons? Yes   No

School Information

High School
College

Gender/Ethnicity/Race

These questions are for statistical purposes only. Your response is optional and does not affect your admission. You will be given another opportunity to provide this information after admission if you wish to do so.
Please indicate your gender:   Male      Female
Are you Hispanic/Latino? Yes      No
If Hispanic or Latino, please indicate your ethnicity (select one)
All applicants please indicate your race (select one or more)
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Additional Information or Comments - Please enter below:

 



 

* The Personal Privacy Protection Law requires this notice to be provided when collecting personal information from individuals. The information on this registration form will be used by SCCC to evaluate your request for admission and will be incorporated into your student records if and when you enroll. Failure to provide the requested information could prevent your application from being processed. The authority to request this information is found in Section 355(2)(h) of the Education Law. This application information will be maintained in the College Records Office. The official responsible for the maintenance of this information is the College Registrar, Suffolk County Community College, 533 College Road, Selden, NY 11784.

Non-Discrimination Notice: Suffolk County Community College does not discriminate on the basis of race, color, religion, creed, sex, age, marital status, gender identity or expression, sexual orientation, familial status, pregnancy, predisposing genetic characteristics, national origin, military or veteran status, domestic violence victim status, or disability in its admissions, programs and activities. For more information, see: www.sunysuffolk.edu/nondiscrimination. The following person has been designated to handle inquiries regarding the College's non-discrimination polices: Civil Rights Compliance Officers, Christina Vargas, Chief Diversity Officer/Title IX Coordinator; Ammerman Campus, NFL BLDG., Suite 230, 533 College Road, Selden, New York 11784; vargasc@sunysuffolk.edu; (631) 451-4950.

Contact Public Safety at any time 24 hours a day/7 days a week (631) 451-4242 or 311 from any College phone. Inquiries may also be directed to the United States Department of Education's Office for Civil Rights, 32 Old Slip 26th Floor, New York, NY 10005-2500; Tel. (646) 428-3800; Email: OCR.NewYork@ed.gov.

All campus crime statistics are available on the College website at www.sunysuffolk.edu/safety.