1. Firstname:
2. Middle Name:
3. Lastname:
4. Date of Birth: January February March April May June July August September October November December 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
5. Primary MCC Campus Attended: Penn Valley Community College Longview Community College Maple Woods Community College Blue River/Blue Springs Comm C MCC Business and Tech Center

Street:
City:
State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zipcode:
 
If you are an International Student attending MCC on a Visa please select your Visa/Permit Type from the list below:


Visa/Permit Type: A1 - Diplomatic or Consular Officer A2 - Oth Officials & Immed Family A3 - Employee Foreign Official AR1 - Alien Registration B1 - Alien Temp Visit Business B1S - Servant to nonimmigrant B2 - Alien Temp Visit Pleasure E1 - Alien Entering US - Trade E2 - Treaty Investor, Spouse &Child F0 - Bona Fide & Qualified Student F1 - Qualified Student F2 - Spouse or Child of F1 Student G1 - International Org Officer G2 - International Org Officer G3 - International Org Officer G4 - International Org Officer G5 - Employee Internat Org Officer H1 - Alien Temp Perform Exceptional H2 - Alien Temp Perform Service H3 - Alien Temp Trainee H4 - Spouse or Child of H1,H2,H3 I - Representative Foreign Media I0 - Repr Foreign Media,Sp/Child J0 - Exchange Visitor Student J1 - Alien Temp Pgm Design J2 - Spouse or Child of J1 K1 - Fiancee/Fiance of US Citizen K2 - Child of K1 K3 - Non Immigrant Spouse of US Cit K4 - Minor Child of K3 Visa Holder L1 - Intracompany Transferee L2 - Spouse or Child of L1 Alien M1 - M1 Visa Type M2 - Dependent of M1 Student N1 - NATO personnel N2 - NATO personnel N3 - NATO personnel N4 - NATO personnel N5 - NATO personnel N6 - NATO N7 - NATO personnel N8 - Nonimmigrant N9 - Nonimmigrant O1 - Person Extraordinary Ability O2 - Personnel of O1 O3 - Dependent of O1 P1 - Famous athlete/entertainer P2 - Exchange athlete/entertainer P3 - Cult Exch athlete/entertainer P4 - Dependent of P1-P3 PR - Permanent Resident Q1 - Cultural Exchange participant Q2 - Cultural Exchange participant Q3 - Cultural Exchange participant R1 - Religious Worker R2 - Dependent of R1 Visa S5 - Alien Witness Informant S6 - Alien Witness Informant S7 - Alien Witness Informant T1 - Alien Victim Person Traffic T2 - Alien Victim Person Traffic T3 - Alien Victim Person Traffic T4 - Alien Victim Person Traffic TD - Dependent of TN Visa TN - Trade NAFTA Agreement U1 - Victim of certain crimes U2 - Victim of certain crimes U3 - Victim of certain crimes U4 - Victim of certain crimes UP - Under Family Unity Program V0 - Other Visa Status - Univ Study V1 - Dependent Permanent Resident V2 - Dependent Permanent Resident V3 - Dependent Permanent Resident WB - Visa Waiver - Business WT - Visa Waiver - Tourist XX - Applicant for Permanent Res St YY - Internet Student

Current Address Same As Permanent Address

Street:
City:
State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zipcode:

1. E-mail Address:
2. Telephone: () - - (xxx)nnn-nnnn

1. Enrollment Term: Fall Spring Summer
2. Enrollment Year:
3. Intended Major:
4. Academic Subplan:

By signing below, I certify that I wish to a participant in the Dual Admission Program between UMKC and MCC. I am aware that my participation in the program will continue to be in effect unless I request in writing to be taken out of the program. I understand that my participation in this program will require the two institutions to share my demographic information and my academic information contained in my educational records maintained by them that relate to my high school experience and/or my time as a student at either institution. Therefore, this constitutes a written consent within the meaning for FERPA to the sharing of that information. I further understand that additional documentation may be required when I decide to become a student at UMKC.

In order to receive the reduced application fee, students must have earned 24 credit hours at MCC and joined this program at least two terms prior to enrollment at UMKC.

By signing this form, I am also accepting UMKC's computer policies. Acceptance of the UMKC Computer Policy is required before a computer username will be issued, to gain access to the computing services provided by UMKC.

I have read the guidelines for participation in the Dual Admission Program between UMKC and MCC.

Electronic Signature (Enter your name):