First name:
Middle initial:
Last name:
Date of Birth:
Gender	Male      Female
E-mail address:
Maiden name:
Social Security Number:
Phone:
Address:
City:
State:
Zip Code:

This course is offered to U.S. Federally Recognized Indian Tribal members. A copy of your tribal identification card or letter of certification from the Tribal Enrollment Official is required. Please fax a copy to:

906-248-3351 Attention: Sherry Bertram
This course is restricted to persons eighteen years of age or older.

Tribal/Band Affiliation:

I was formerly enrolled as a Bay Mills Community College student.
I am currently enrolled as a Bay Mills Community College student.
I am not currently a Bay Mills Community College Student.

How did you hear about this course?
E-mail Advertisement
Friend or Relative
Employer
Indian Country Today Website
Tribal Paper     Which Tribal Paper?
Other     

SPECIAL STUDENT STATUS

High school transcripts or GED scores are not required for this class as students will be enrolled under "special student status".

Please note that students who wish to enroll in regular programs of study will be required to submit their official high school or GED transcript.

By submitting this form, I certify that all answers given in this application are complete and accurate to the best of my knowledge.

I  have dated this application with my own hand on  .