Semester: Fall semester 20 _ Spring semester 20 __ Summer Semester 20 ______
Legal Name: ____________________________________________ CSI ID#: ________ _____________ Date of Birth:
last first middle
Mailing Address: ________________________________________ Social Sec Num: Gender: Female Male
_____________________________________________ Home Phone: Citizen of:
US Other
city state zip code
Previous last Name______________________________ E-Mail Address:
________________________________ Major Code: _ _
Marital Status:
D Divorced
M Married
S Single
W Widow/Widower
Father’s Education Level
0 Some high school/ 5 Some college education
Secondary school but but no bachelor’s degree
did not graduate 7 Bachelor’s degree or higher
4 Graduated from high school or
earned GED but no college
Mother’s Education Level
0 Some high school/ 5 Some college education
Secondary school but but no bachelor’s degree
did not graduate 7 Bachelor’s degree or higher
4 Graduated from high school or
earned GED but no college
Ethnic Group:
A Asian
B Black/African American
I American Indian/Alaskan Native
P Native Hawaiian or other Pacific
Islander
W White/Caucasian
Anticipated Time to Complete Educational Objective:
1 Less than 1 semester
2 1 to 2 semesters
3 3 semesters
4 4 semesters
5 More than 4 semesters
6 Unknown
Number of children or dependents
Advisor’s Signature: Student’s Signature: Date:
Advisor’s Comments:
Note: The advisor’s signature indicates that you have spoken with an advisor, but you are ultimately responsible for making decisions that lead to your academic success. REV 7/12
Current Education Level:
0 Less than high school
1 Completing high school
2 Completing GED
3 GED graduate
4 High school diploma
5 Some college, no degree
6 Associate degree or certificate
7 Bachelor’s degree or higher
Educational Objective:
1 Personal Enrichment
2 Get a job
3 Improve skills for current job
4 Get a different job
5 Earn a 1-yr certificate
6 Earn a 2-yr degree (no transfer
7 Transfer to 4-yr school without
CSI degree
8 Transfer to 4-yr school with CSI
degree
9 Other
Hispanic of any race Yes No
Employment Status During this Semester:
1 I am employed part-time (less
than 35 hrs/wk)
2 I am employed full-time (more
than 35 hrs/wk)
4 I am not currently employed but I am
seeking work
5 I am not currently employed and not
seeking employment
Family Status of Student:
1 I am a single parent with my children or
dependents
2 I live with my spouse/partner with children
or dependent
3 I live with my parents and do not
have dependents.
4. other
Aud
Section # Ex(Math 143 M01)
Cr Hrs
Course Title
Bldg
Rm
Days
Time
Instructor
M T W R F S U
De
g
ree Seekin
g
Course Re
g
istration
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signature
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