Choose one of the following:
Race/Ethnic Group: answer both 1 & 2 below
This information, required of educational institutions by federal or state law, will be used solely for reporting purposes. You may voluntarily provide this information.
- Ethnicity: Are you of Hispanic or Latino origin? Yes No
- Race: Choose one or more from the list below
Country of Citizenship
Are you a U.S. Citizen? Yes
No. If not, please complete the following:
Are you a Permanent Resident? Yes
No If yes, list alien
If you are not a U.S. Citizen or Permanent Resident, please state your Visa or immigration status in detail:
Certification of Information:
Applicant Name: Date
I certify that this information is true and accurate. I understand that any misrepresentation, omission or incorrect information shall be cause for disciplinary action up to dismissal, with no right of appeal or to a tuition refund.
Parent/Guardian Name(Applicant is Under 18 Years Old): Date
Use this space to send additional information, or send any questions you may have.
Use the following buttons to either send your application to
Middlesex Community College or to clear the information from the form.
To avoid delays in processing your MIDDLENET Quick Registration Form, make sure you have carefully completed the entire form before submitting it.
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