Alabama Community College System

Institution name:
College Name:
Date:
Address:
Chief Executive Officer of the institution:
Name and title of person completing this form:
If not shown above:
Telephone:
Fax:
E-mail:
Web Site:

Check all that apply:

• Accredited by an accrediting agency recognized by the U.S. Department of Education.

• Attach a copy of the most recent notice(s) of accreditation and a copy of team report(s).

• Are you aware of any pending complaints?

Yes No

If yes, provide a brief explanation.

• Is the accreditation in good standing (not in warning, probation, or other status)?	YesNo
If no, provide a brief explanation.

• Licensed/Approved in other state(s) (list states).

AlabamaHawaiiMichiganNew YorkTennessee
Alaska IdahoMinnesotaNorth CarolinaTexas
ArizonaIllinoisMississippiNorth DakotaUtah
ArkansasIndianaMissouriOhioVermont
CaliforniaIowaMontanaOklahomaVirginia
ColoradoKansasNebraskaOregonWashington
ConnecticutKentuckyNevada PennsylvaniaWest Virginia
DelawareLouisianaNew HampshireRhode IslandWisconsin
FloridaMarylandNew JerseySouth CarolinaWyoming
GeorgiaMassachusettsNew MexicoSouth Dakota

• List the states in which the institution operates but is exempt from state licensure.

• Is licensure or approval in good standing in each state (not in warning, probation, or other
status)?

Yes No If no, attach explanation.