Fillable CCS Quick Admit Application Form Ccs 40-212 (Spokane Community College)

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CCS Quick Admit Application Form Ccs 40-212 (Spokane Community College)

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Page 1 of 2
CCS 40-212 12/18
Marketing and Public Relations
Community Colleges of Spokane
QUICK ADMIT APPLICATION FORM
FOR OFFICE USE ONLY
Date Received:
To comply with federal laws, we are required to ask for your Social Security Number (SSN) or Individual Taxpayer
Identification Number (ITIN). We will use your SSN/ITIN to report Hope Scholarship/Lifetime Learning tax credit; to
administer state/federal financial 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 civil penalties (refer to Internal Revenue Service Treasury Regulation 1.6050S-1(e)(4) for more information).
Pursuant to state law (RCW 28B.10.042) and federal law (Family Educational Rights and Privacy Act), the college will
protect your SSN from unauthorized use and/or disclosure.
SOCIAL SECURITY NUMBER (###-##-####)
CCS STUDENT IDENTIFICATION (if applicable)
Year
Summer (July – Aug.)
Fall (Sept.-Dec.)
Winter (Jan.-March)
Spring (April-June)
Which location do you plan to attend?
SFCC:
Fairchild
SCC:
Colville
Ione
Republic
Online
Pullman
Inchelium
Newport
Last name (Legal)
First name (Legal)
M.I.
Previous last name(s)
Mailing address
Apt. no.
Day telephone
City
State
ZIP
Evening telephone
E-mail address
Birth date (mm/dd/yy)
Gender (voluntary)
/ /
Female Male
ETHNICITY AND RACE INFORMATION
Are you of Spanish/Hispanic/Latino ethnicity? (Providing this information is voluntary.)
No
Yes: Cuban
Yes: Mexican, Mexican American, Chicano
Yes: Other Spanish/Hispanic/Latino
Yes: Puerto Rican
(please specify)
Which race do you consider yourself to be? Choose one or more. (Providing this information is voluntary.)
African-American
Japanese
Other Asian
Alaskan Native
Korean
Other Pacific Islander
American Indian
Native Hawaiian
Other race (please specify below)
Chinese
Vietnamese
Filipino
White/Caucasian
CITIZENSHIP INFORMATION
Are you a U.S. citizen? Yes No - If not a U.S. citizen, country of citizenship?
If not U.S. citizen, what is your visa status?
Temporary resident: Alien no.
Visitor
Immigrant/Permanent resident: Alien no.
International student (with F or M visa)
Refugee/Parolee or Conditional Entrant: Alien no.
Other
VETERANS INFORMATION
NOTICE: Veterans may qualify for educational benefits. Please check the box if you are a military
veteran or a Guard/Reservist who has been deployed.
Page 2 of 2
CCS 40-212 12/18
Marketing and Public Relations
WASHINGTON STATE RESIDENCY INFORMATION
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.)
Yes No
If no, how long have you lived continuously in the state of Washington?
Months
2. Were you claimed for federal income tax purposes by your mother, your father, or your legal guardian
in the current calendar year?
Yes No
In the past calendar year?
Yes No
If YES, has your mother, father, or legal guardian lived continuously in the State of Washington for
the past 12 months?
Yes No
3. Will a public or private non-federal agency/institution outside the state of Washington provide you
with financial assistance to attend college (for example, an Alaskan student loan)? (NOTE: Answer
yes only if your eligibility for this assistance is based on being a resident of that state.)
Yes No
4. Are you active duty military stationed in Washington or a member of the Washington National Guard?
Yes No
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?
Yes No
Effective July 1, 2003, Washington State law changed the definition 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 financial aid. To qualify for resident status, students must complete an affidavit/declaration/certification 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 (3) 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 (3) 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 attend and request a copy
of the 1079 residency form.
PREVIOUS EDUCATION
Name
City/St
From:
Year (YY)
To:
Year (YY)
Graduate?
Last High School
Attended
Yes: Year
No: Highest grade
level completed
Have you successfully completed the GED test? Yes No
If yes, list institution name,
location, and year earned:
Name
City/St
From:
Year (YY)
To:
Year (YY)
Graduate?
Last college,
vocational/technical
school attended
EDUCATIONAL GOALS – I INTEND TO (PLEASE CHOOSE ONE OPTION BELOW)
OPTION 1: Take courses for personal enrichment only – please select one
(Students selecting these options are not able to receive financial aid):
Take classes to upgrade my job skills but do not plan to earn a degree or certificate.
Take classes for my own personal enrichment.
OPTION 2: Transfer credits
APPLICANT’S SIGNATURE
I certify that my responses on this form are true.
Required applicant’s signature
Date
Community Colleges of Spokane shares educational records within the district.
Community Colleges of Spokane 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.
Return signed and completed form by e-mail or in person to the appropriate office listed below:
Spokane Community College
Spokane Falls Community College
Admissions Office Bldg 15
1810 N Greene St
Spokane WA 99217-5399
509-533-8020
SCC.Admissions@scc.spokane.edu
www.scc.spokane.edu
Admissions Office Bldg 17
3410 W Ft George Wright Dr
Spokane WA 99224-5288
509-533-3500
SFCC.Admissions@sfcc.spokane.edu
www.spokanefalls.edu
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CCS Quick Admit Application Form Ccs 40-212 (Spokane Community College)

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Completed 8 October 2020

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