Adult & Continuing Education Application

INSTRUCTIONS: Please carefully read and complete this form in its entirety. Any questions may be directed to the Director of Adult and Continuing Education by calling 631.656.2102 or by emailing [email protected].
Identifying Information
Applicant Name
First*
Middle
Last*
Date of Birth*
Gender*
- Male
- Female
- Prefer Not To Say
My permanent address is located within:*
- United States
- Canada
- Other country
Permanent Address*
Street Address Address Line 2 City State ZIP Code
Permanent Address*
Street Address Address Line 2 City Province Postal Code
Permanent Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone Type
- Domestic (US/Canada) Number
- International Number
Cell Phone Number*
By providing a cell phone number, I consent to receive SMS/text messages from Five Towns College.
Cell Phone Number (International)*
By providing a cell phone number, I consent to receive SMS/text messages from Five Towns College.
Primary Email Address*
Enter Email Confirm Email
Secondary Email Address
Enter Email Confirm Email
Race
- American Indian or Alaska Native
- Hispanic
- Asian
- Black or African American
- Native Hawaiian or Other Pacific Islander
- Nonresident Alien
- Not Specified
- Race and Ethnicity Unknown
- Two or more races
- White/Caucasian
Are you Hispanic/Latino of any descent?
- No
- Yes
Are you a U.S. Citizen?*
- Yes, I am a U. S. citizen (U. S. national)
- No, but I am an eligible noncitizen.
- No, I am not a citizen or eligible noncitizen.
Social Security Number*
If you are an eligible noncitizen, please provide your eight- or nine-digit Alien Registration Number below. Generally, you are an eligible noncitizen if you are :
1. A permanent U.S. resident with a Permanent Resident Card (I-551);
2. A conditional permanent resident with a Conditional Green Card (I-551C);
3. The holder of an Arrival-Departure Record (I-94) from the Department of Homeland Security showing any one of the following designations: “Refugee,” “Asylum Granted,” “Parolee” (I-94 confirms that you were paroled for a minimum of one year and status has not expired), T-Visa holder (T-1, T-2, T-3, etc.) or “Cuban-Haitian Entrant;” or
4. The holder of a valid certification or eligibility letter from the Department of Health and Human Services showing a designation of “Victim of human trafficking.”
If you are in the U.S. and have been granted Deferred Action for Childhood Arrivals (DACA), an F1 or F2 student visa, a J1 or J2 exchange visitor visa, or a G series visa (pertaining to international organizations), select “No, I am not a citizen or eligible noncitizen.” You will not be eligible for federal student aid. If you have a Social Security Number but are not a citizen or an eligible noncitizen, including if you have been granted DACA, you should still complete the FAFSA because you may be eligible for state or college aid.
Alien Registration Number
Visa Information
If not a US citizen or permanent resident, please provide the information below.
Type of Visa Admission ID Number and/or DACA #
Have you ever been convicted of a felony ?*
- Yes
- No

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Previous Education
Highest Level of Education Achieved*
Name of High School
Year of Graduation
Name of Last School or College Attended*
Unofficial Transcript
If you have attended College previously, please also submit a copy of your unofficial transcript from any institutions attended for evaluation purposes.
Max. file size: 50 MB.
Have you been suspended and/or expelled from a previous College for disciplinary reasons?*
- Yes
- No
Program of Study
Starting Term*
Please indicate the Associate Degree Program (60 credits) that you are interested in applying:
If employed, what is the name of the company you work for now?

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Personal Statement
Essay Upload
Please write and upload an essay (Minimum of no less than 50 words) addressing why you wish to enroll in our online classes and how this will help you achieve your career/professional goals. (.DOC, .DOCX or PDF Formats accepted)
Accepted file types: doc, docx, pdf, Max. file size: 5 MB.
Review, Sign, and Submit
Please confirm that the following information that you have entered is correct: {all_fields}
Application Agreement*
By signing below, I certify that the information provided in this form is true and correct to the best of my knowledge.
- I agree to the terms of the Application Agreement
Name
First Last
Signature
Date: 04/16/2024

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Adult & Continuing Education Application

Step 1 of 3

Identifying Information

Previous Education

Program of Study

Personal Statement

Review, Sign, and Submit