BRIDGE PROGRAM ENROLLMENT FORM

1.

Student Information

First Name
Middle Name
Last Name
Gender
Date of Birth	Day	Month	Year (YYYY)
Phone
Permanent Address
Mailing Address (If diferent from above)
City
State
Zip Code
Email Address
Completed number of Midland Technical College credits (if none, list 0)
Anticipated # of Midland Technical College credits before transferring
Have you ever applied to SC State University before?
What is your major at Midland Technical College?
Intended SC State University Major
Term student plans to enter SC State University in

2.

School Information

High School graduation/GED Completion date
Have you ever completed a Columbia College Application?
Technical School you are/will be attending
Anticipated entry term at CC
Program:
Anticipated CC major
Cumulative College GPA
Are you planning to live on campus after transferring?

3.

Referral Information

Complete this section with your advisor if you are a current student at Midland Technical College and plan to transfer to SC State University at least one semester from now.

Advisor Name
Date	Day	Month	Year (YYYY)
Department at Midland Technical College
Contact Information - Phone
Advisor Email

*4.

STATEMENT OF INTENT

If I enroll in the bridge program, I understand that Columbia College will be in communication with my academic advisor
regarding my course selections and academic performance. I understand by signing this form I am giving Columbia College
permission to access this information.

By electronic signing and submitting this form, I acknowledge that I have read, understood, and agreed to its terms and conditions.

Printed Name

BRIDGE PROGRAM ENROLLMENT FORM - Columbia College