Fillable CERRITOSCOLLEGEApplication 3 2012 Form Master

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CERRITOSCOLLEGEApplication 3 2012 Form Master

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APPLICATION FOR ADMISSION
11110 Alondra Blvd., Norwalk, CA 90650 • (562) To-Learn or (562) 865-3276 • www.cerritos.edu
Any identification provided on this form is maintained for student records purposes and for reporting to state and federal agencies. For financial aid and tax reporting purposes
you must provide your social security number, your major and your anticipated graduation date. For more information, see the Cerritos College Catalog under Admissions Policy.
Please answer the questions as they pertain to the beginning of the semester for which you are applying. Please complete in ink.
1. Legal Name
Last First Middle Prior
2. Social Security Number – –
3. Gender (please check one) ❏ Male ❏ Female 4. Marital Status: ❏ Single ❏ Married ❏ Unknown
5. Birthdate Age *students under the age of 18 and not a high school graduate must submit a Special Admit Minor form with application
6. Place of Birth
City State or County
7. Citizenship (proof may be required). Please check the appropriate number:
❏ 1. U.S. citizen, by birth or naturalization (date):
❏ 2. Not a U.S. citizen, hold permanent resident visa, date issued:
❏ 3. Not a U.S. citizen, amnesty recipient, date issued:
❏ 4. Not a U.S. citizen, but a refugee, parolee or asylee, date issued:
❏ 5. Not a U.S. citizen, hold a student visa (F-1, M-1, J-1 or J-2).
❏ 6. Other, not a U.S. citizen, hold other visa or visa type unknown.
8. Telephone number, including area code ( ) -
9. Email Address
Note: Reliable internet access and email address are REQUIRED for online classes.
10. Ethnic Background (please check appropriate box). The data gathered is used for state and federal reporting purposes. This question is
voluntary and will not be used to discriminate admission to the College.
11. Address while attending Cerritos College (No PO Boxes, please)
Number Street Apt# City Zip Code
12. Mailing address, if different from above (PO Box okay)
Number Street Apt# City Zip Code
13. Semester applying for: ❏ ❏ Spring ❏ ❏Summer ❏❏ Fall Year: 20
(Check one - one application per semester.)
Cerritos College I.D. Number
Have you ever been employed by Cerritos College? ❏Yes ❏No
❏ 1. Chinese
❏ 2. Asian Indian
❏ 3. Japanese
❏ 4. Korean
❏ 5. Laotian
❏ 6. Cambodian
❏ 7. Vietnamese
❏ 8. Other Asian
❏ 9. Black
❏ 10. Filipino
❏ 11. Hispanic
❏ 12. Mexican
❏ 13. Central American
❏ 14. South American
❏ 15. Other Hispanic
❏ 16. American Indian/
Alaskan
❏ 17. Guamanian
❏ 18. Hawaiian
❏ 19. Samoan
❏ 20. Other Pacific
Island
❏ 21. White
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14. Please enter your major area of study. If “undecided” enter “undecided”.
Enter program title here:
Required
Please mark the type of classes you plan to enroll in:
❏ Credit Classes ❏ Non-Credit Adult Education
❏ Special Programs (e.g., Nursing, Court Reporting, Physical Therapist Assistant, Teacher TRAC, etc.)
15. Enrollment Status: ❏ 1. Currently enrolled in grade K-12 ❏ 4. Returning (attend Cerritos but not last semester)
❏ 2. New (never attended any college) ❏ 5. Returning Transfer (attend Cerritos but attended another college)
❏ 3. New Transfer (attended college but not Cerritos) ❏ 6. Continuing (currently enrolled or attended Cerritos last semester)
16. Last high school attended?
Date of Graduation
(mm/dd/yy)
Name and location of high school if not listed above.
Name City County State
17. Last college or university attended? If you received a diploma, certificate or degree,
what year did you receive it? (year) If none, please enter last year attended (year)
Name and location of college or university, if not listed above.
Name Street City State Zip
Name Street City State Zip
Name Street City State Zip
18. Are you comfortable reading and writing English? ❏ Yes ❏ No
❏ Artesia (4582)
❏ Columbus (4646)
❏ John Glenn (4836)
❏ Somerset (4614)
❏ Tracy (4583)
❏ Bellflower (4612)
❏ Downey (4647)
❏ La Mirada (4837)
❏ St. John Bosco (2612)
❏ Valley Christian (2578)
❏ Centennial (4898)
❏ El Camino (4840)
❏ Mayfair (4613)
❏ St. Joseph (2593)
❏ Warren (4648)
❏ Cerritos (4581)
❏ Gahr (4585)
❏ Norwalk (4839)
❏ St. Matthias (2611)
❏ Whitney (4584)
❏ Compton (2051)
❏ El Camino (2052)
❏ LA Pierce (2058)
❏ LA Valley (2061)
❏ Mt. SAC (2065)
❏ Santa Ana (2098)
❏ CSU Fullerton (1945)
❏ UC Irvine (1826)
❏ Azusa Pacific (264)
❏ Whittier (884)
❏ Cypress (2091)
❏ Fullerton (2092)
❏ LA Southwest (2059)
❏ Orange Coast (2095)
❏ Santa Monica (2072)
❏ CSU Long Beach (1920)
❏ UC Los Angeles (1810)
❏ Biola (280)
❏ East Los Angeles (2053)
❏ LA Mission (2064)
❏ LA Trade Tech (2060
❏ Long Beach City (2070)
❏ Rio Hondo (2067)
❏ CSU Dominguez Hills (1917)
❏ CSU Los Angeles (1810)
❏ UC Riverside (1833)
❏ USC (879)
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❏ 000 No longer in high school and not a high school graduate
❏ 200 Currently enrolled in Adult School
❏ 400 Passed the GED, or received high school certificate or equivalency
❏
600 Received foreign secondary school diploma/certificate
❏ 800 Received a Bachelor’s Degree or higher
❏ 100 Currently enrolled in K-12
❏ 300 Received a high school diploma
❏ 500 Passed the C.H.S.P.E.
❏ 700 Received an Associate’s Degree
❏ XXX None
❏ 1. Obtain an A.A. degree and transfer to a 4-year institution
❏ 2. Transfer to a 4-year institution without an A.A. degree
❏ 3. Obtain a 2-year Associate’s Degree without transfer
❏ 4. Obtain a 2-year vocational degree without transfer
❏ 5. Earn a vocational certificate without transfer
❏ 6. Discover/formulate career interests, plans, goals
❏ 7. Prepare for a new career (acquire job skills)
❏ 8. Advance in current job/career (update job skills)
❏ 9. Maintain certificate or license (e.g., nursing, real estate)
❏ 10. Educational development (intellectual, cultural)
❏ 11. Improve basic skills in English, reading or math
❏ 12. Undecided
❏ 13. Non-Credit to Credit
❏ 14. 4-year College Student Requirements
19. What is your highest level of education? (SB11)
For the above question, what year did you receive the diploma, certificate or degree?
If none, enter the last year attended. (year)
20. What is your immediate educational goal? (SB14)
Military Status- (Only completed by active military persons, veterans discharged within the last year, or dependents of active duty personnel)
21. Will you be on active duty in the armed services stationed in California on the opening day of the semester in which you plan to enroll?
❏ Yes ❏ No If yes, when did your current duty in California begin?
22. Is California indicated on your last Leave and Earnings Statement? ❏ Yes , submit your last LES ❏ No
23. Were you discharged from the armed services within the last year? ❏ Yes , date of discharge ❏ No, submit DD214
24. Are you the dependent or spouse of a person on active duty in the armed services stationed in California at the start of the term in which you
plan to enroll? ❏ Yes ❏ No
25. If yes, when did his/her current duty in California begin? Proof of dependent identification card required.
To be an eligible veteran, the student must have served at least 180 days of active duty with a discharge under conditions other than dishornorable. Only service
with a branch of the U.S. military is considered.
26. Workforce Investment Act-(WIA) Veteran Status
❏ Unknown/Unreported ❏ Not a WIA eligible veteran ❏ WIA eligible spouse of veteran ❏ WIA eligible veteran
27. Student-Military Status yes no 28. Parent/Guardian-Military Status yes no
Currently serving on active duty ❏❏ Currently on active duty ❏❏
Veteran ❏❏ Veteran ❏❏
Member of the Active Reserve ❏❏ Member of the Active Reserve ❏❏
Member of the National Guard ❏❏ Member of the National Guard ❏❏
29. Did you attend a California high school for three or more years and earn a diploma or equivalent? ❏ Yes ❏ No
30. What was your G.P.A. in high school? ❏ A (4.0) ❏ B (3.0+) ❏ C (2.0+) ❏ Below 2.0
31. What are your parents’/guardians’ highest levels of education?
32. How many people do you support (provide more than half of their housing, food, and expenses)? Please include yourself in the count.
Parent #1
Parent #1
Parent #2
Parent #2
❏ 9th grade or less
❏ some high school
❏ High school graduate
❏ college, no degree
❏ A.A. degree
❏ B.A. degree
❏ M.A. degree
❏ I don’t know
❏ none, I’m supported by family/spouse
❏ only me
❏ two, including me
❏ three, including me
❏ four, including me
❏ five or more, including me
RESIDENCY QUESTIONNAIRE
TO BE COMLPLETED BY ALL STUDENTS
PART 1 - State laws regulate admission of students on the basis of legal residence. This statement is a certification necessary to administer the laws. If additional information is
needed to determine your residence status, you will be required to complete a supplemental residence questionnaire and/or to present evidence in accordance with the Educational
Code Sections 68040 et. seq. The burden of proof to clearly demonstrate both physical presence in California and intent to establish California residence lies with the student.
33. Where have you resided the past 24 months?
City State MM/DD/YY MM/DD/YY
City State MM/DD/YY MM/DD/YY
Complete questions 34-40 about you. If you are unmarried and under 19 years of age, complete about your parents.
no yes If Yes, what year?
34. Filed personal state income tax to another state? ❏ ❏
35. Voted in another state? ❏ ❏
36. Attended an out-of-state educational institution as a resident of that state? ❏ ❏
37. Declared residency in another state for income tax purposes? ❏ ❏
38. Petitioned for divorce in another state? ❏ ❏
39. Possessed a valid driver’s license in another state? ❏ ❏
40. Registered a vehicle in another state? ❏ ❏
41. Are you a displaced homemaker? Yes ❏No❏(A homemaker is someone who has been away from the job market for at least 7 years and now needs training to
gain job skills due to a loss of financial support)
42. Please estimate the number of hours per week you work during the semester.
❏ N=not employed ❏ A=1-9 hrs ❏B=10-19 hrs ❏C=20-29 hrs ❏D=30-39 hrs ❏E=40+hrs
43. Are you receiving benefits from? ❏ AFDC ❏TANF ❏GA/GR ❏WIA ❏SSI
44. I am a Tech-Prep Student ❏ Yes ❏No
45. Total household income in the previous year: ❏ $ 16,425 or less ❏$ 16,426 - 21,855 ❏$ 21,856 - 27,465
❏ $ 27,466 - 33,075 ❏$ 33,076 - 38,685 ❏$ 38,686 or more
46. Disabled Student Services : Do you wish information regarding disability accommodations? ❏ Yes ❏No
❏Physical ❏Vision ❏Hearing ❏Learning ❏Communication ❏Psychological
47. Are you interested in receiving information regarding financial aid? ❏Yes ❏No
48. Would you like to be contacted for services for former foster youth? ❏Yes ❏No
49. Are you a migrant worker or child of a migrant worker? ❏Yes ❏No
50. I’m interested in participating in an intercollegiate sport (not all sports may be currently available):
PART 2-IF YOU ARE UNDER 19 YEARS OF AGE WHEN CLASSES BEGIN-COMPLETE THE FOLLOWING:
Give names and permanent legal residence for the following persons. If deceased, enter the word “deceased.” SHOW ADDRESSES TO COVER AT LEAST 2 YEARS
Use legal/permanent address, DO NOT USE A PO BOX.
Father’s Name US Citizen ❏ Yes ❏No
Current Address
Number Street City State Zip Since (mm/dd/yy)
Previous Address
Number Street City State Zip Since (mm/dd/yy)
Mother’s Name US Citizen ❏ Yes ❏No
Current Address
Number Street City State Zip Since (mm/dd/yy)
Previous Address
Number Street City State Zip Since (mm/dd/yy)
**Cerritos College maintains directory information which consists of but is not limited to: student name, major field of study, dates of attendance, degrees, and awards received.
❏Yes, release directory information ❏No, do not release directory information
I certify under oath or penalty of perjury that the statements made in this application are true and complete to the best of my knowledge. I understand that falsification,
withholding pertinent data, or failure to report changes in residence, may result in my dismissal.
STUDENT’S SIGNATURE DATE
Admissions and Records 3/2012
❏ Badminton (Women’s)
❏ Baseball (Men’s)
❏ Basketball
❏ Cross Country
❏ Field Hockey (Women’s)
❏ Football (Men’s)
❏ Golf
❏ Gymnastics (Women’s)
❏ LaCrosse
❏ Skiing/Snowboarding
❏ Soccer
❏ Softball (Women’s)
❏ Swimming/Diving
❏ Tennis
❏ Track & Field
❏ Volleyball
❏ Water Polo
❏ Wrestling (Men’s)
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CERRITOSCOLLEGEApplication 3 2012 Form Master

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Completed 12 May 2020

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