Dual Credit Application
Submission of this application certifies that the information on this application is true and complete without evasion or misrepresentation to the best of your knowledge. You further acknowledge that you understand if the information submitted is found to be otherwise, it is sufficient cause for rejection or dismissal with forfeiture of all my fees and deposits. Further, you agree to accept and abide by all rules, regulations, and policies established by the Board of Trustees of MACC.
Please be accurate and precise in answering the application questions. This form is handled electronically, and entry errors may be transferred to your permanent College record. It is essential that entries use upper- and lower-case format (ie. should be John Smith NOT john smith as one may text nor JOHN SMITH). Spell out words and do not use punctuation (ie. use County Road not CR, Street not Str. or St. or other abbreviations unless the space in the form restricts complete entry.
Moberly Area Community College is committed to a policy of non-discrimination on the basis of race, color, national origin, gender, sexual orientation, disability, age, marital or parental status, religion, genetics, ancestry, or veteran status, in admissions, educational programs, activities, or employment.
All inquiries concerning non-discrimination, including equal opportunity and Title IX, should be directed to the Title IX Coordinator: Cheryl Lybarger, Moberly Area Community College, Director of Health Sciences,101 College Avenue, Moberly, MO 65270, 660-263-4100 ext. 11369
Inquiries concerning Section 504 of the Rehabilitation Act of 1973, which guarantees access to education regardless of disability, should be directed to: Stacy Donald, Director of Access and ADA Services, Moberly Area Community College, Columbia Higher Education Center, Room 119, 601 Business Loop 70 West, Columbia, MO 65203, 573-234-1067, ext. 12120
*SSN is required if you are applying for Financial Aid or are expecting a 1098-T
You must provide your legal first/middle/last name as it appears on your Social Security Card or International Visa.
OPTIONAL: Only choose suffix if you use this as part of your legal name
Please provide other former legal names by which you have been known. For example, birth name or maiden name.
*Please be sure your birth year is correct.
What country were you born in?
Permanent Legal Address
If you are a dependent and claimed or could be claimed on parent/legal guardian's Federal Income Tax return per Internal Revenue Service (IRS) guidelines, your Permanent Legal Address is your parent/legal guardian's principal residence.
If you are at least 22 years of age or emancipated (student is not under the care, custody or support of parents or legal guardians) your Permanent Legal Address is the address where you currently reside.
County - only Missouri (Illinois or Iowa counties as noted are listed). Choose UNLISTED at the bottom of the drop down, if you do not reside in one of the counties shown in the drop down.
Primary Phone Number
Please do not use a high school email account for your personal email provided below.
Personal Email Address
Confirm Email Address
Have you lived at this address for more than 1 year?
If you have at your current permanent address for less than 1 year, provide the requested information about your most recent previous address.
Previous Zip Code
Last date you lived at the previous address.
Current Mailing Address
Is your current mailing address the same as your Permanent Legal Address?
Mailing Zip Code
What country are you a citizen of?
If you are a permanent resident of the US, please provide the date in which your permanent resident status became effective. Your permanent resident card will be required for registration.
If you hold a valid US Visa, select the visa type:Your visa and additional information will be required for registration.
This information is requested for the purpose of reporting to Federal Compliance agencies and will not be used in determining admission status. Your response to the information is strictly voluntary.
What academic year are you taking classes for college credit? An academic year begins in August and ends in July.
What term do you plan to start?
Fall classes is August-DecemberSpring classes is January-AprilSummer classes is May-July.
Choose your intended enrollment status
Choose a program of study.
What type of student are you?
What high school do you currently attend?
Enter the high school you are currently attending.
State of Institution
Please provide the name and primary phone number of the person you wish to have listed as an emergency contact.
Missouri law, MO SB 197 (RS 199.290), requires all Missouri institutions of higher education to perform a tuberculosis screening process for all students enrolling in college. Answers to the following questions are required. If your answer to each of these questions is NO, further action is not required. If you answer YES to any of the questions, you must provide proof of a negative TB test taken within the last year. Please contact Student Affairs for more information if applicable.
Have you had contact with a person know to have active tuberculosis (TB)?
Were you born in or have you lived for more than two months in Asia, Africa, Central of South America, or Eastern Europe?
Have you ever been a health care worker?
Have you volunteered or worked in a nursing home, prison or other residential institution?
Have you ever been diagnosed with or treated for latent tuberculosis infection or active tuberculosis disease?