Admissions

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Application for Admission - Dual

Section 1: Dual Enrollment
Page 1 of 1
Personal Information

Please enter your legal name as it appears on your birth certificate. If you have a preferred name, please enter it in the field provided.

1. 

First Name

*Required, Maximum characters allowed: 30
2. 
Middle Name
Maximum characters allowed: 30
3. 
Legal Last Name
*Required, Maximum characters allowed: 60
4. 

Preferred Name

Maximum characters allowed: 30
5. 
Suffix
6. 
Social Security Number:    
Format: 123-45-6789
7. 
Email Address
Format: x@x.xx
8. 
Cell Phone Number
Format: 123-456-7890
Biographic Information
9. 
Date of Birth       
*Required, Format: mm/dd/yyyy
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10. 
Gender
11. 
Ethnicity
12. 
Race
Permanent Address
13. 
Address
*Required, Maximum characters allowed: 60
14. 
City
*Required, Maximum characters allowed: 25
15. 
State     
*Required
16. 
Zip Code
*Required, Format: 12345 OR 12345-6789 OR 123456789 OR A1B 2C3
17. 
County (New Mexico Only) 
18. 
Phone Number                     
Format: 123-456-7890
19. 

What year do you plan to enroll at Mesalands Community College?

*Required
20. 

In what semester do you plan to enroll at Mesalands Community College?                              

*Required
High School Information
21. 
New Mexico STARS ID Number
Maximum characters allowed: 10
22. 

Which High School are you currently enrolled at?      

*Required
23. 

Anticipated High School Graduation Date (mm/dd/yyyy)

Format: mm/dd/yyyy
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Please select the Next button to review and submit your application
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