Fillable ADMISSION FORM - - PLEASE PRINT (Clover Park Technical College)

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ADMISSION FORM - - PLEASE PRINT (Clover Park Technical College)

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PROGRAM CODE INTENDED MAJOR AREA OF STUDY
PLAN YEAR QUARTER START
PREFERRED TIME OF CLASS
STUDENT ID NUMBER LAST NAME FIRST NAME MI BIRTHDATE SEX
SOCIAL SECURITY NUMBER PREVIOUS LAST NAME (If applicable)
E-MAIL ADDRESS
TELEPHONE CONTACT NUMBERS
I do not wish to disclose my social security number.
INITIAL: DATE:
__________________________________________________
This information is used for several purposes:
• to administer nancial aid
• to verify academic records
• to conduct research
• to report payments you made that may qualify for
a tax credit or a tax deduction on your income tax
return
In keeping with state and federal law, the college will
protect your SSN/ITIN from unauthorized use and
disclosure. We are required to ask for your SSN/ITIN.
If you do not disclose it, you will still be able to enroll
at the college, but may be subject to an IRS penalty
of $50.
CURRENT MAILING ADDRESS (STREET OR P.O. BOX) APT #
CITY STATE ZIP CODE
ACADEMIC HISTORY
LAST HIGH SCHOOL ATTENDED CITY STATE YEARS ATTENDED GRADUATED
LAST COLLEGE, VOCATIONAL, OR TECHNICAL ATTENDED CITY STATE YEARS ATTENDED GRADUATED
RACE AND CITIZENSHIP INFORMATION
Are you a U.S. Citizen? YES NO
If not a U.S. Citizen, what is your visa status?*
International student - F J, or M Visa (F1/M1) No Answer
Temporary resident (T), Alien #: ______________________________________________
Permanent Resident (IM), Alien #: ____________________________________________
Refugee/Parolee or Conditional Entrant (RF), Alien #: ____________________________
Other Visa (ZZ), Explain: ____________________________________________________
*SUBMIT A COPY OF YOUR IMMIGRATION DOCUMENTATION WITH THIS APPLICATION
Which race do you consider yourself to be? Please mark up to 2 choices. (Voluntary)
Are you Spanish or Hispanic origin? (Voluntary)
TESTING INFORMATION
STATUS INFORMATION
Have you taken the GED Test?
If yes, date earned (Month/Year): ______________________
Where did you earn your GED? (School/organization name):
__________________________________________
Which of the following pre-college tests have you taken?
In what year did you take your last pre-college test?
_________________________________________________
NON-DISCRIMINATION POLICY: Clover
Park Technical College does not discriminate on the basis of race, color, national origin, sex, disability, sexual orientation/
gender identity, veteran’s status, religion, or age in its program and activities. The following office has been designated to handle inquiries regarding the non-
discrimination policies:
LIMIT OF LIABILITY: The c
Chief Human Resources and Legal Affairs Officer, 4500 Steilacoom Blvd SW, Lakewood, WA 98499. Telephone (253)589-5533.
ollege’s total liability
for claims arising from a contractual relationship with the student in any way related to classes or programs shall be limited to the tuition and expenses paid by the student to the
College for those classes or programs. In no event shall the College be liable for any special, indirect, incidental, or consequential damages, including but not limited to, loss of
earnings or profits. By signing this document, student agrees to be bound by CPTC policies and procedures as set forth in the Student Handbook and online.
STUDENT SIGNATURE:
DAY
EVENING
EMERGENCY
CONTACT
EMERGENCY
DAY
YES
YES
to
to
EVENING
NO
NO
BOTH
MALE FEMALE
White (800)
African American (872)
American Indian (597)
Alaska Native (015)
Native Hawaiian (653)
Pacic Islander (681)
Vietnamese (619)
Filipino (608)
Chinese (605)
Korean (612)
Japanese (611)
Other Asian (621)
Other Race (specify)
No (999)
Yes, Mexican, Mexican American,
Chicano (722)
Yes, Cuban (709)
Yes, Puerto Rican (727)
Yes, Other Spanish/Hispanic/Latino (specify)
Veterans and/or their dependents may
qualify for educational benefits. Please call
the VA at 1-888-442-4551 or go to
www.gibill.va.gov for more information.
YES NO
ACCUPLACER
ACT
ASSET/COMPASS
SAT
ADMISSION FORM
4500 STEILACOOM BLVD SW
LAKEWOOD, WA 98499
NEW STUDENT
PLEASE PRINT
FORMER STUDENT
( ) -
_______________________
( ) -
_______________________
( ) -
_______________________
_______________________
- -
- -
DATE:
CONTACT
PERSON
Have you served in the U.S. Armed Forces? (V$)
Parent's Education Level: Has either of your parents earned a bachelor's (4-year) degree? (F!)
Foster Youth: Have you been in Washington State foster care for at least one year since your 16th birthday? (F$)
YES NO
RESIDENCY INFORMATION - Please read the following notice before responding to the questions in this section:
Effective July 1, 2003, Washington state law changed the denition of “resident student.” The law makes certain students eligible for resident
student status – and eligible to pay resident tuition rates – when they attend public colleges and universities in this state. The law does not
make these students eligible to receive need-based state or federal nancial aid. To qualify for resident status, students must complete this
afdavit/declaration/certication if they have met the following conditions:
• Condition One: (a) Resided in Washington State for three years immediately prior to receiving a high school diploma, and (b) Complete
the full senior year at a Washington high school, and (c) Continuously resided in the State since earning the equivalent of a high school
diploma.
• Condition Two: (a) Completed the equivalent of a high school diploma, and (b) Resided in Washington State for the three years
immediately before receiving the equivalent of the diploma, and (c) Continuously resided in the State since earning the equivalent of a high
school diploma.
NOTE: If you meet one of the above conditions and would like to pay resident tuition rates,
contact the college(s) you are applying to and request the Residency Afdavit form.
Residency Questions for Tuition Purposes
1. Have you been a legal resident* of Washington and lived continuously in the State of Washington for the past 12 months?
*A student cannot qualify as a legal resident of Washington for tuition calculation purposes if s/he possesses a valid out-of-state driver’s
license, vehicle registration, or other documents that give evidence of being a legal resident in another state.
If no, how long have you lived continuously in the state of Washington? _________ Months
2. a. Were you claimed for federal income tax purposes by your mother, father, or legal guardian in the current calendar year?
b. In the past calendar year?
If YES to either 2a or 2b, has your parent or legal guardian lived continuously in Washington State for the past 12 months?
3. Will a public or private non-federal agency/institution outside the state of Washington provide you with nancial assistance to attend
college? (Answer yes only if your eligibility for the assistance is based on being a resident of the state)
4. Are you active duty military stationed in Washington or a member of the Washington National Guard?
Are you the spouse or dependent of either (a) an active duty military person stationed in Washington, or (b) a member of the Washington
National Guard?
SUBMIT SUPPORTING DOCUMENTATION WITH THIS APPLICATION
YES NO
YES
YES
NO
NO
YES NO
YES NO
YES NO
YES NO
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ADMISSION FORM - - PLEASE PRINT (Clover Park Technical College)

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Completed 4 February 2021

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