Non-Degree Student Application Form

You can be assured that all information is encrypted and transmitted securely.

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 request.
  • Press "Send" to mail your request.

Personal Information

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

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 convicted of a felony? Yes  No
Have you ever been suspended from college for disciplinary reasons? Yes  No

For what purpose are you attending SCCC?
Choose the one response which best describes your intentions:

1. Uncertain/no definite purpose in mind
2. To take a few courses for job-related advancement
3. To take a few courses for self-improvement
4. To take courses and transfer to a non-State University of New York (SUNY) school prior to completing a degree
4a. To take courses and transfer to a State University of New York (SUNY) school prior to completing a degree
5. To obtain or maintain a license or certification (i.e. without completing a degree)
6. To complete a one-year certificate program
7. To complete an associate’s (two-year) degree for entry into the workforce
8. To complete an associate’s (two-year) degree and transfer to a non-State University of New York (SUNY) school bachelor’s (four-year) degree program
8a. To complete an associate’s (two-year) degree and transfer to a State University of New York (SUNY) school bachelor’s (four-year) degree program
9. Non-applicable

School Information

High School
College

Ethnicity/Race (for statistical purposes only)

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: