NHLRA and CCSNH Hospitality COVID-19 Readiness – White Mountains Community College

A Collaboration of White Mountains, Lakes Region and Nashua Community Colleges

General Information
Social Security Number (last four digits)*
Last four digits of Social Security Number
Date of Birth*
MM slash DD slash YYYY

Date of Birth
Name*
First Middle Last
Former Names (i.e maiden name) listed on school records
First Last
Address*
Street Address City State ZIP Code
Mailing Address (if different from above)
Street Address Address Line 2 City State ZIP Code
Email*
Home Phone/Cell Phone*
Work Phone
Ethnicity (optional)
- White, Non-Hispanic
- Black, Non-Hispanic
- Asian
- American Indian/Alaskan
- Hispanic
Employer Information
Employer Contact Information*
Employer Name Street Address City State ZIP Code
Your work position*
New Hampshire Residence Information
I have always lived in New Hampshire
- Yes
- No
If no, what month and year did you move to NH?
Current state of residence if not New Hampshire
To be signed by all applicants
The information provided by the applicant on this admission application form shall be held confidential to the extent determined by Federal Law and College policy. The Community College System of New Hampshire reserves the right to deny admission to any applicant who, in the judgement of the college officials, does not qualify for admission. The College also reserves the right to require withdrawal of any student who does not satisfy the ideals of citizenship, character, or scholarship. In accordance with the terms and conditions set forth in its publications, and if accepted to abide by the rules and regulations set forth in the publications and in the Student Handbook, I also agree that the College has permissions to use any College sponsored pictures in which any likeness appears. I certify that I have read and agree with the above, and that all information provided herein is true and complete. For compliance purposes, the Community College System of New Hampshire and its Colleges collects names and social security numbers from all students attending the college. For example, the Internal Revenue Code requires the college to produce a 109-T tax form. The college’s use of social security numbers will be limited to legitimate educational purposes. The college will ensure the security of the student’s social security number and will not disclose it to anyone outside the college, except as authorized by federal or state laws or applicable policies.
Signature*
Date*
MM slash DD slash YYYY

A Collaboration of White Mountains, Lakes Region and Nashua Community Colleges

General Information

Employer Information

New Hampshire Residence Information

To be signed by all applicants