Gcidlast Four Digits of Social Security #Date of Birth (Mm/Dd/Yyyy)

1. 2. 3.

GCIDLast Four Digits of Social Security #Date of Birth (mm/dd/yyyy)

4.

Last NameFirst NameMiddle InitialPreferred

5.

Street AddressCity, State Zip Code

6.

Mailing Address (if different)City, State Zip Code

7.( ) 8. ( ) 9.

Permanent Phone NumberCell Phone NumberEmail Address

10. Program of Study
11. Have you ever attended Mississippi State University?
YES NO / 12. If yes, when?
Semester Year
Under the Partnership the student will

1. Complete the Partnership Application by the appropriate deadline. Priority application deadlines: Fall – July 1, Spring – November 1; Summer – May 1
2. Complete the application for admission for Mississippi Gulf Coast Community College, complete admission requirements and be admitted as a student at Mississippi Gulf Coast Community College in the desired program of study.
3. Attend orientation for the Partnership Program at MGCCC.
4. Be admitted as a transient studentat Mississippi State University and enroll at MGCCC in an Associate degree program. Student must meet MSUtransfer admission requirements upon the completion of the Associates Degree at MGCCC.
5. Each semester/term ensure the Support Institution provides the Home Institution with a Support Institution academic transcript upon completion of the semester/term.
6. By virtue of signing this document, I authorize the Registrar at MGCCC and the Registrar at MSU to verify enrollment and forward an unofficial transcript between the two institutions. Official transcripts cannot be released if fees are owed at the issuing institution.
7. Maintain satisfactory academic progress as published in the policy of the Home Institution.
8. To remain eligible, student must maintain enrollment in 6 or more hours.
9. Enroll in courses as prescribed by the desired Partnership program of study outline as certified by his or her Home Institution advisor and satisfy minimum grade point requirements as specified by the degree program.
10. If applying for Federal Financial Aid, complete the Student Financial Aid Consortium Agreement
11. File a FAFSA with both Mississippi State University& Mississippi Gulf Coast Community College school code and complete the required financial aid process prior to all applicable deadlines. Note: A separate application for Summer financial assistance is required. Students are required to satisfy requirements, specified by the State or Institution, to be awarded State or Institutional financial aid.
12. Pay tuition, fees, and other expenses as charged by Mississippi State University& Mississippi Gulf Coast Community College. Any refund from the Home Institution will be issued to the student who will be obligated to pay outstanding tuition and fees to the Support Institution.

Applicant SignatureDate
Mississippi Gulf Coast Community College is an Equal Opportunity Employer and welcomes students and employees without regard to race, color, religion, national origin, sex, age or qualified disability. For further information, contact the Equal Opportunity Officer at a Mississippi Gulf Coast Community College Center, Campus, or the District Office. Compliance is coordinated by the Vice President for Administration and Finance, Perkinston Campus, P. O. Box 609, Perkinston, Mississippi 39573, telephone number 601-928-5211.