11. Date of Birth (MM/DD/YY)
12. Are you a U.S. Veteran?
Yes
No
13. Are you a U.S. Citizen?
Yes
No
If no, then are you in the U.S. on a Visa?
Yes
No
Are you a permanent resident?
Yes
No
If you are not a U.S. Citizen or Permanent Resident,
please provide:
Visa Type Visa No.
14. I am a legal resident of: City/Village/Township (circle one)
City/Township County State
15. Name of high school district in which you now reside
1. Legal name: Last First Middle
2. Former last name(s) (if applicable)
3. Permanent address Street or R.F.D. Box number
4. City State Zip Code
5. Mailing address (if different) Street or R.F.D. Box number
6. City State Zip Code
7. Phone number Other/Mobile phone number
8. E-mail address 9. Gender:
Male
Female
10. Social Security Number
18. I wish to attend Technical College at Campus
19. Have you attended this college before?
Yes
No If yes, last year and semester attended
20. Semester you wish to begin:
Fall
Winter/Spring Year
21. Program/major choice Program code # (if known)
22. Name of last high school City State
Are you a high school graduate?
Yes
No If yes, please enter your graduation date (month/year)
23. If you did not complete high school and receive a diploma, have you completed either the GED
®
Tests
Yes
No or HSED?
Yes
No
If yes, date completed Administrator
24. Have you taken a high school course for technical college credit? (such as Youth Apprenticeship, Certified Nursing Assistant, Certified Co-ops)
Yes
No
(transcript or certificate required for verification)
25. Circle highest grade completed: 8 9 10 11 12 13 14 15 16 17 over
26. List previous colleges and universities attended (official transcript will be required for credit transfer)
Name City State/Province Date attended Date graduated
27. I certify that the information on this application is true and complete to the best of my knowledge
Date Signature
APPLICATION
FOR
ADMISSION
PLEASE TYPE OR PRINT IN INK
FOR OFFICE USE ONLY
1. Student classification: 1. New 2. Re-entry 2. Transfer 3. Date received 7. Admit Status
Note STATEAP 04/09
( ) ( )
16-17. The following questions are confidential. Your responses will help the technical college evaluate recruitment and retention practices and will not
affect admission to the college. Question 16(a) and 16(b) relate to racial and ethnic identity. Please respond to both questions.
16(a). Are you Hispanic or Latino (a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race)?
Yes
No
16(b). Select any other group or groups that apply to you.
American Indian or Alaska Native. A person whose ancestors include native peoples of North and South America (including Central America),
and who maintains a tribal affiliation or community attachment.
Asian. A person whose ancestors include native peoples of the Far East, Southeast Asia or the Indian subcontinent (including, for example,
Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam).
Black or African American. A person whose ancestors include any of the black racial groups of Africa.
Native Hawaiian or other Pacific Islander. A person whose ancestors include the native peoples of Hawaii, Guam, Samoa or other Pacific Islands.
White. A person whose ancestors include native peoples of Europe, the Middle East or North Africa.
17. Have either of your parents completed a four-year college degree or beyond?
Yes
No
