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
oered 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 bachelors (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 Pacic 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 ______________________________ Todays Date _____________
click to sign
signature
click to edit
Please return the admissions form to the college you plan to attend.
Pierce College Fort Steilacoom
Admissions Oce
9401 Farwest Drive SW
Lakewood, WA 98498-1999
(253) 964-6501
Pierce College Puyallup
Admissions Oce
1601 39th Avenue SE
Puyallup, WA 98374-2222
(253) 864-3254
www.pierce.ctc.edu
Military Sites
If you wish to attend classes at our military sites, it is necessary to submit an admissions form, if you plan to apply for nancial
aid. Because military term dates dier, please contact the sites for information on classes, advising and registration.
Pierce College at Fort Lewis
(253) 964-6567
Pierce College at McChord
(253) 964-6606
Social Security Number Disclosure Statement
To comply with federal laws, we are required to ask for your Social Security Number (SSN) or Individual Taxpayer Identication Number
(ITIN). We will use your SSN/ITIN to report payments made by you that may qualify for a tax credit or a tax deduction on your income tax
return. We may also use this information to administer state/federal nancial aid, to verify enrollment, degree and academic transcript
records, and to conduct institutional research. If you do not submit your SSN/ITIN, you will not be denied access to the college; however,
you may be subject to an IRS penalty of $50. Pursuant to state and federal law, the college will protect your SSN from unauthorized use
and/or disclosure.
Residency Information
Eective July 1, 2003, Washington State law changed the denition of “resident student. The law makes certain students, who are not permanent residents or
citizens of the United States, 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
an adavit/declaration/certication if they are not permanent residents or citizens of the United States but have met one of the following conditions:
Condition One: (a.) Resided in Washington State for three years immediately prior to receiving a high school diploma, and (b.) Completed the full senior
year at a Washington high school, and (c.) Continuously resided in the state since earning the 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 these conditions and would like to pay resident tuition rates, contact the Admissions Oce at either college (phone numbers
are listed above) and request a copy of the Adavit/Declaration/Certication Form for HB1079. You may also download and print o a copy by
accessing our website at www.pierce.ctc.edu/dist/tuition/guidelines.
Veterans Information
The Veterans Education Benets Oces (VEBO) at Fort Steilacoom and Puyallup help veteran students complete their applications and
request forms for benets from the Veterans Administration. Visit www.gibill.va.gov to see which chapters benets you may qualify for.
You are also encouraged to apply for Financial Aid and scholarships at the college.
Commitment to Diversity
Pierce College oers a variety of academic, nancial, cultural, and personal support services to interested students and is committed to
enrolling a diverse student body.
The Pierce College District does not discriminate on the basis of race, color, creed, religion,
national origin, sex, sexual orientation, age, gender, marital status, disability, or status as a
disabled or Vietnam era veteran.
1506 AF