Berkshire Community College

1350 West Street

Pittsfield, MA  01201

(413) 236-1662

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Student Government Ambassadors

Application Information

Name:  ______________________________

Mailing Address:________________________

E-Mail:_______________________________

Academic Information                                         List of References and Telephone Numbers

Major:___________________________       I._________________________________ 
                                       
                                                                             II._________________________________

Anticipated Graduation Date:__________      III._________________________________

                                                                                                (faculty, staff or current employer)

Please respond to the following question in the space provided.  Your answers do not need to be extensive in length; however they do need to answer the question completely.

 By signing this document you acknowledge that all of the information contained herein is true
to the best of your knowledge.  Additionally, you are permitting the Office of Student Life
to verify your enrollment status as a student at Berkshire Community College.

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                      Signature                                                                                              Date