Prospect Inquiry

Contact Information

In order to enroll in a CC2BSU program you must meet one of the following criteria and currently be enrolled at your community college:

1) You applied to BSU and did not meet the admit criteria at BSU and have been directed to enroll in MCC2BSU or BCC2BSU.

2) You’ve been accepted and have enrolled in courses at Bristol Community College or Massasoit Community College with 33 or fewer earned credits. Students with more than 33 earned credits may still be eligible and should consult with a CC2BSU advisor regarding their eligibility.

First Name

Last Name

If you have a prior last name or maiden name, please state it here:

P.O. Box / Street Address

Street Address (Apt., Suite, etc.)

Foreign Address:

City

State/Province

ZIP/Postal Code

Address 1: Country

Address 1: Cellphone

Email Address

If you previously applied to BSU and used this email address as your contact email, you will need to provide a separate email address in order to successfully complete the CC2BSU enrollment process. Please do not use your high school email address.

Confirm Email Address

Date of Birth (mm/dd/yyyy)

Make sure the year in your DOB is correct!

Gender

Citizenship Status

Race Information (Optional)

Ethnicity

American Indian or Alaska NativeYesNo

Black or African AmericanYesNo

AsianYesNo

Native Hawaiian or Other Pacific IslanderYesNo

WhiteYesNo

Cape VerdeanYesNo

College Information

Which Program Are You Interested In?

Community College Major (if known)

How many college credits have you completed?

Please indicate the semester you began College

Referral Source

Enrollment to BSU Information

Planned Entry Term to BSU

Academic Level of Interest

I will be entering as a...

Decision Plan

Academic Discipline

Academic Program

Are you interested in campus housing?

Emergency Contact Information

Relationship to you

First Name

Last Name

Area Code

Phone

Street Line 1

Street Line 2

City

State/Province

ZIP or Postal Code

Disciplinary History

Academic Disciplinary History

Have you ever been charged with or placed on probation, suspended, removed, dismissed or expelled as a result of a disciplinary violation, whether related to academic misconduct or behavioral misconduct at any educational institution you have attended from the 9th grade (or international equivalent) forward?

YesNo

Adjudication Disciplinary History

Have you ever been adjudicated guilty or convicted of a misdemeanor, felony, or other crime? (Note: you are not required to answer “yes” to this question, or provide an explanation, if the criminal adjudication or conviction has been expunged, sealed, annulled, pardoned, destroyed, erased, vacated, impounded, or otherwise ordered by a court to be kept confidential and/or is excluded pursuant to MA General Law Chapter 151C, Section 2(f).

YesNo

Certification & Signature

Do you certify the following?

I understand that once my application has been submitted it may NOT be altered in any way.

YesNo

Do you certify the following?

I certify that all of the information submitted in the application is my own work, factually true, and honestly presented. I authorize all schools attended to release all requested records and authorize review of my application. I understand that I may be subject to a range of possible disciplinary actions, including admission revocation or expulsion, should the information I certified be false.

YesNo

Do you certify the following?

I understand that an offer of admission is conditional, pending receipt of final transcripts showing work comparable in quality to that upon which the offer was based.

YesNo

By signing my signature below, I authorize that the information above may be shared between Bristol Community College and Bridgewater State University for purposes associated with the BCC2BSU program. I understand that I am enrolling in the BCC2BSU program and indicate that I understand the benefits associated with the BCC2BSU program. If at any point I wish to opt out of the BCC2BSU program, I will contact Bridgewater State University’s Associate Director of Transfer Services, Jeffery Sarahs at j1sarahs@bridgew.edu to discuss the process. As a BCC2BSU student participating in programs, events, and campus related activities at Bridgewater State University I understand that I am responsible for abiding by and adhering to all institutional policies at Bridgewater State University as well as those represented at my respective community college. I understand that violations outlined within Bridgewater State University’s Student Handbook and Student Code of Conduct are subject to BSU’s standard conduct review process and such incidents may be reported to my respective Community College. I understand that the information shared between Bridgewater State University and my community college includes but is not limited to: student record information, student involvement records, academic records, incident reports, and public safety/police reports.

By signing my signature below, I authorize that the information above may be shared between Massasoit Community College and Bridgewater State University for purposes associated with the MCC2BSU program. I understand that I am enrolling in the MCC2BSU program and indicate that I understand the benefits associated with the MCC2BSU program. If at any point I wish to opt out of the MCC2BSU program, I will contact Bridgewater State University’s Associate Director of Transfer Services, Jeffery Sarahs at j1sarahs@bridgew.edu to discuss the process. As a MCC2BSU student participating in programs, events, and campus related activities at Bridgewater State University I understand that I am responsible for abiding by and adhering to all institutional policies oat Bridgewater State University as well as those represented at my respective Community College. I understand that violations outlined within Bridgewater State University’s Student Handbook and Student Code of Conduct are subject to BSU’s standard conduct review process and such incidents may be reported to my respective community college. I understand that the information shared between Bridgewater State University and my community college includes but is not limited to: student record information, student involvement records, academic records, incident reports, and public safety/police reports.

Signature

Signature Date