Educational History
Please complete accurately and completely the instructions for each numbered column below.
Location of School
(City, State, & Country)
Name of
Certificate/ Degree
& Date Earned
CERTIFICATION - to be read and authorized by all applicants to certify the accuracy of the information provided.
I certify under penalty of perjury under the laws of the State of California that I have provided complete and accurate responses to all
the items on this application. I further certify that all official documents submitted in support of this application are authentic and
unaltered records that pertain to me. I authorize the California State University to release any information submitted by me in this
application for admission and any application for financial aid to any person, firm, corporation, association, or government agency to
verify or explain the information I have provided or to obtain other information necessary for my application for admission and any
application for administration of financial aid and in connection with any perjury proceedings. I authorize the California State
University system to release any submitted test results to all campuses to which I submit an application. My certification verifies the
accuracy and completeness of the information provided. I understand that any misrepresentation or omission may be cause for denial
or cancellation of admission, transfer credit, or enrollment. I certify that so long as I am a student at this institution, I will advise the
residence clerk if there is a change in any of the facts affecting my residence.
I agree to meet the California State University comprehensive health insurance requirement for the duration of
studies/practical training as listed on my I-20 or DS-2019 form.
Signed at
Country Applicant's Signature Date
Nondiscrimination Policy-- The California State University does not discriminate on the basis of race, color, national origin, sex, physical
handicap or sexual orientation in the educational programs or activities it conducts.
