Primary Name:
Middle
Last
Former/Maiden Name
Campus
Home Address
City Zip
Student ID#
Home Phone #
Cell Phone #
Date of Birth
E-mail Address
Pre-Apprentice Citizenship
Sex
Female
Male
Mexican, Mexican American,
Chicano
Central American
South American
Hispanic: Other
Asian: Indian
Asian: Chinese
Asian: Japanese
Asian: Korean
Asian: Laotian
Asian: Cambodian
Asian: Vietnamese
Asian: Filipino
Student Signature: _____________________________ Date: ___________
Revised 3/16/2018
Semester
Fall
Winter
Spring
Summer
Year
Suffix
State
What is your race? Check one or more:
American Indian/Alaskan Native
(A person having origins in any
of the original peoples of North
and South America (Including
Central America) who maintains
cultural identification through tribal
affiliation or community attachment)
Pacific Islander: Guamanian
Pacific Islander: Hawaiian
Pacific Islander: Samoan
Pacific Islander: Other
(A person having origins in any of the
original peoples of Hawaii, Guam,
Samoa, or other Pacific Islands)
White
(A person having origins in any of the
original people of Europe, Middle
East, or North Africa)
Mailing Address
City State
(Do not use PO Box or Business Address)
APPLICATION FOR NONCREDIT ADMISSION
This application is strictly for noncredit 0 unit courses.
Main Educational Goal
Earn a career technical
certificate without tranfer
Discover/formulate career interests,
plan, goals
Prepare for a new career (acquire
job skills)
Advance in current job/
career (update job skills)
Maintain certificate or
license
Complete credits for high school
diploma or GED
To move from noncredit
coursework to credit coursework
Educational Development
Improve basic skills
Undecided on goal
OFFICE USE ONLY
Processed By
Date
Zip
NOTE: If you are a continuing noncredit student transitioning to credit you will need to fill out the on-line
CCCApply application and select Educational Goal, "To move from noncredit coursework to credit coursework"
(If different from Home address)
Social Security #
(Students are required by law to provide their Social Security Number, which will
be used for reporting to the federal government under the Taxpayer Relief Act of
1997 and for financial aid verification. If you do not have a Social Security
Number, or if you do not wish to use it, please leave blank.)
Ethnic Identity
Are you of Hispanic or Latino
Ethnicity?
Yes No
If Yes, Check all that apply:
Highest Education Status
Full name of last High School attended:
Name of High School: ______________________
City: ___________________________________
State/Foreign Country: _____________________
Graduation Date (mm/dd/yyyy):
Last college attended, not including LACCD
College: If none, check this box
Name of College: _________________________
City: ____________________________________
State/Foreign Country: _____________________
From (mm/dd/yyyy):
To (mm/dd/yyyy):
FERPA - Student Information - Permission to Release
I do not permit the release of my information to four-year
colleges
I do not permit the College to release directory information
I do not permit the release of my information to the College
Foundation
I do not permit the release of my information to the military
Basic Skills
English as a Second Language
Vocational Education
Academic Plan
First-time Student in college (after leaving high school)
First time at this college; have attended another college
Returning student to this college after absent for a main term
Enrolled in high school (or lower grade) and college at the same time
Enrollment Status
Asian: Other
(A person having origins in any of the
original people of the Far East, Southeast
Asia, or the Indian Subcontinent)
Black or African American
(A person having origins in any of the black
racial
groups of Africa)
Primary Language
Chinese (Other)
English
Japanese
Korean
Russian
Tagalog
(Philippines)
Spanish
Vietnamese
Arabic
Armenian
Chinese (Cantonese)
Chinese (Mandarin)
Chinese (Shanghai)
Non-Descrimination Policy
All Programs and activities of the Los Angeles Community College District shall be operated in a manner which is free of discrimination on the basis of actual or perceived ethnic group identification,
race, color, national origin, ancestry, religion, creed, sex (including gender identity and gender-based sexual harassment), pregnancy, marital status, cancer-related conditions of an employee, sexual
orientation, age, physical or mental disability, or veterans status. (LACCD Board Rules, Chapter 15.)
In order to ensure the proper handling of all civil rights matters, the District has an Office of Diversity Programs. Direct initial inquiries to the Office of Diversity Programs at (213) 891-2000.
Primary
Primary
First
22
23
Tourist Visa
Do you have a B1 or B2 Visa?
Yes No
Farsi (Persian)
