Iowa Central Distance Education

Iowa Central Application for Distance Education Courses
* indicates a required field

Personal Information

*First Name:

*Middle Name/Initial:

*Last Name:

*SSN:

*Birth Date:

Sex/Marital Status:

Female/Married Male/Married
Female/Single Male/Single

Maiden Name:

*Address:

City:

County:

State:

Zip Code:

*Phone:

Work Phone:

*E-Mail:

Iowa Resident: Yes No
Date of residency:

US Citizen: Yes No - If No:

Country of birth:
Country of citizenship:
Type of Visa:

Is English your native language?

Yes No

Ethnicity: (optional)

Emergency Contact Information

Contact:

Father Mother
Spouse Guardian

Other:

*Name:

*Phone:

Program Major Information

*I am pursuing a major in:

Admissions Information

Center:

Term:

Have you ever taken a credit course at Iowa Central? Yes No

What center?
Year(s)
Degree(s)

Identify your reason for attending Iowa Central:

To meet certification/licensure requirements

Transfer to another college

Explore courses to decide on a career

Self-improvement/Improve basic skills

Prepare to enter the job market

Undecided/Unknown

Improve skills for present job

Prepare to change careers

Personal Interest

While enrolled, I plan to be employed:

15 hours or less per week

16-25 hours per week

26-39 hours per week

40 hours per week

More than 40 hours per week

Do not plan to be employed

How long do you plan to attend Iowa Central:

One semester One year or less Two years Three Semesters

Are you a U.S. Military veteran?: Yes No

Will you receive Veteran's benefits?: Yes No

Are you the first in your family to attend college

Yes No

I received information about Iowa Central from:

Another Student

High School Counselor

My Parents

My Employer

High School Teacher

Newspaper

Radio

Other

Admissions Representative

Iowa Central Coach

Iowa Central Employee

Mail from Iowa Central

High School Information

*High School/GED:

*Graduated/Completed:

City:

State:

Have you ever earned college credit from any other college or university?
Yes No

Full name of institution(s):

Degrees earned after high school:

Certificate Diploma Associate
Bachelor Master Doctoral

College:

Please be sure to fill out the form completely, this will speed up your enrollment process.