ADMISSIONS FORM
INCOMPLETE FORMS WILL NOT BE PROCESSED.
_________________________________________________________
Last name First name Middle initial
_________________________________________________________
Previous name(s)
_________________________________________________________
Mailing address
_________________________________________________________
City State Zip
________________________________________________
Social Security Number (See reverse for Social Security Number disclosure information.)
( ) ( )
________________________________________________
Day telephone Evening telephone
________________________________________________
Email address
Birthdate:
Month/Day/Year
_______________ Gender*: r Male r Female
*Providing this information is optional.
SID
SHADED AREAS FOR
OFFICE USE ONLY
STUDENT PROGRAM
ADMISSIONS NO.
DATE FORM REVD
PAID
Please indicate which college you would like to attend:
r Pierce College Fort Steilacoom r Pierce College Puyallup
r Joint Base Lewis McChord
I plan to attend: r days r evenings r both
Have you ever applied to or attended classes for credit
oered by this college? r Yes r No
Quarter and year you plan to start:
r Fall r Winter r Spring r Summer 20 _______
Do you plan to transfer to a four-year college? r Yes r No
Do you plan to be here for only one quarter? r Yes r No
What is your intended major area of study?
Have either of your parents earned a bachelor’s (four-year) degree?
r Yes r No
Name of current or last high school attended:
_____________________________ ________________________
Name of high school City, State
Date of intended or actual graduation from high school:
___________________
Month/Year
Graduated?
r Yes r No
HS CODE
If you earned a GED instead, indicate date of GED:
___________________
Month/Year
GED CODE
Name ALL colleges currently or previously attended:
______________________________ ____________
School Year
____________________________
City, State
Graduated?
r Yes r No
COLLEGE CODE
______________________________ ____________
School Year
____________________________
City, State
Graduated?
r Yes r No
COLLEGE CODE
______________________________ ____________
School Year
____________________________
City, State
Graduated?
r Yes r No
______________________________________________________
COLLEGE CODE
Are you a U.S. Citizen? r Yes r No
If No, what type of VISA do you have:
r Resident Alien/Immigrant* (#__________)
r Student (F-1 or M-1)
r Refugee (RF)
r Visitor (B)
r Other: _________________________________
*Please attach a copy of both
sides of your Permanent
Resident Alien Card or the I-94
Card so we may determine your
residency for tuition-paying
purposes.
CITIZEN
Washington State Residency Status
Please answer questions 1-6
1. Have you been a legal resident* of Washington and lived
continuously in Washington for the last 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.
RESIDENCY CODE
FEE PAY STATUS
r Yes
r No, I have only lived continuously in the state of
Washington for ______ months.
2. a. Were you claimed for federal income tax purposes by your mother,
father, or legal guardian in the current calendar year? r Yes r No
b. … in the past calendar year? r Yes r No
c. If YES, has your mother, father or legal guardian lived continuously in the
state of Washington for the past 12 months? r Yes r No
3. Will a public or private non-federal agency or institution outside the state
of Washington provide you with nancial assistance? r Yes r No
4. a. Are you active duty military stationed in Washington or an active
member of the Washington National Guard? r Yes r No
b. Are you the spouse/dependent of an active duty military person
stationed in Washington state? r Yes r No
c. Are you the spouse/dependent of an active member of the Washington
National Guard and live in Washington state? r Yes r No
5. Have you been in Washington State foster care for at least one year
since your 16th birthday? r Yes r No
6. Are you a veteran or a dependent of a veteran? r Yes r No
PROVIDING THE FOLLOWING INFORMATION IS VOLUNTARY AND
DOES NOT AFFECT YOUR ENROLLMENT AT PIERCE COLLEGE
What race do you consider yourself t
o be?
r African American (872)
r Alaska Native (015)
r American Indian (597)
r Chinese (605)
r Filipino (608)
r Japanese (611)
r Korean (612)
r Native Hawaiian (653)
r Vietnamese (619)
r White (800)
r Other Asian (621)
r Other Pacic Islander (681)
r Other Race (please specify)
______________________
Are you of Spanish/
Hispanic/ Latino ethnicity?
r No
r Yes, Cuban (709)
r Yes, Mexican, Mexican
American, Chicano (722)
r Yes, Puerto Rican (727)
r Yes, Other Spanish/Hispanic/
Latino (please specify)
_______________________
I certify that, to the best of my knowledge, all statements on this form are true.
Print Your Name _______________________________ Applicant Signature ______________________________ Today’s Date _____________
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