APPLICATION FOR ADMISSION
YEAR
Term & College for which you are applying:
Admissions Application for
If you plan on taking classes at BOTH colleges within this District, make sure you have a current application AT EACH COLLEGE
OFFICE USE ONLY
Colleague ID #
Date
NAME
LAST
FIRST
M.I.
Legal Name
1
Evergreen Valley College
Last Name
First Name
Middle Initial
Address
2
Number & Street
Apt. Number
City
State
Zip Code
Telephone Number
3
Origin
4
Social Security Number
(Necessary for Financial Aid applicants)
5
6
Birth Date
Gender
8
Male
Female
E-Mail Address
9
Major/Academic Program
10
CODE
Admit Status (Fill in the one which best applies to you)
11
(Form R-40 required)
(Form R-42 required)
Student’s Educational Goal (Choose One)
12
Are you eligible for Veteran's Benefits?
13
If yes:
Fill in the categories that are of interest to you:
15
specify
MM
DD
YY
Ethnic Background
7
AA African/American
AC Asian/Chinese
AI Asian/Indian
AJ Asian/Japanese
AK Asian/Korean
AL Asian/Laotian
AM Asian/Cambodian
AV Asian/Vietnamese
AX Asian/Other
C Caucasian/Non-Hispanic
FI Filipino
H Hispanic
HCA Hispanic/Central America
HM His/Mex Hisp/Amer
HSA Hispanic/South America
HX Hispanic/Other
NA Native American
OTH Other Non-White
P Pacific Islander
PACG Pac Islander/Guam
PACH Pac Islander/Hawaiian
PACS Pac Islander/Samoa
PACX Pac Islander/Other
UNK Unknown
XD Decline to State
A Asian
FALL
SPRING
SUMMER
Mobile
Home
Walk-In
Mail
Email
JS I plan to enroll in college while still in K-8.
HS I plan to enroll in college while still in high school.
RS I am returning to this college after an absence of one or more terms.
N I am attending college for the first time after high school.
X Unreported/Uncollected goal (Office use only)
A Earn an Associate Degree and transfer
B Transfer to a four-year college without an Associate Degree
C Earn an Associate Degree without transferring
D Earn a Vocational Degree without transferring
H Advance in current job/career (update job skills)
E Earn a Vocational Certificate without transferring
F Discover/formulate career interests/plans/goals
G Prepare for a new career (acquire job skills)
I Maintain certificate or license (e.g. Nursing, Cosmetology)
J Educational development (intellectual, cultural)
K Improve basic skills in English, Reading and Math
L Complete credits for high school diploma or GED
M Undecided on goal
yes
no
Self
As a Dependent
1 Financial Aid Assistance
3 Disabled Student Services
2 Child Care Services
4 Transfer Center Services
5 Job/Career Assistance
6 Basic Skills Assistance
8 English as a Second Language (ESL)
7 Tutoring Assistance
9 Extended Opportunity Program & Services (EOP&S)
10 Student Government & Activities
14 Asian-Pacific Special Programs
11 Latino Student Special Programs
13 Intercollegiate Athletic Programs
12 African-American Special Programs
15 Accelerated Transfer Programs
16 Sport
San Jose/Evergreen Community College District
Language most frequently Spoken/Written: (Choose one - optional)
14
specify
English
Spanish
Tagalog
Vietnamese
Chinese
Other
Save As
Print Form
Submit by E-mail
Graduation type: (Check the type that best describes your highest educational background)
18
16
Institutional
History (HS)
High School Last Attended
City
State
HIGH SCHOOL CODE
SIGNATURE REQUIRED Read the following CAREFULLY before signing
I declare under penalty of perjury that the statements and information submitted in this Admissions Application are true and correct. I understand that all materials submitted by
me for purposes of admission are true and correct. Falsification, withholding pertinent data or failure to report changes in residency or education status may result in District
action. I understand that all materials submitted by me for purposes of admission become the property of the San Jose/Evergreen Community College District. In registering for
future terms, I agree to provide true and correct information about any changes in my educational status.
OFFICE USE ONLY
Residency Status
1
2
3
4
1
Special Admit:
Student Type
2
3
4
5
6
7
(No SS#, Add ID# to DADD)
Application Status
Date
Information entered by
Colleague ID#
Remarks
Incomplete
Accepted
NAE
PERC
ASPR
SPRO
DADD
SHAP
FINF
PPIN
STAL
STRK
SREP
R-42 on file
R-40 on file
FC
CSEA
INST
EMPL
OST
IHSC
OSTE
INT
OHSC
OHSH
REG
Residency Information
19
State laws regulate student fees on the basis of California residence.
This statement is a certification necessary to administer the laws.
A From the date of this application, have you continuously lived in California for at least one year and one day?
OFFICE USE ONLY
date
date
B If you answered NO to part A, and you want to be considered a California resident for enrollment purposes, answer the residency questions
in both sections below.
Are you an active member of the US military or a dependent?
Are you a dependent of a parent who is a California resident?
Have you, or if you are under 19 years of age, have your parents, any time during the past two years:
Registered to vote in a state other than California?
Petitioned for divorce in another state?
Been declared a non-resident of California for state income tax purposes?
Attended an out-of-state institution as a resident of that other state?
If you are unmarried and under 19 years of age, have you lived with one or both parents for the past two years at a California address?
If YES, give the address
C Citizenship Select ONE.
4 Currently enrolled in
adult high school
1 Received a high school
diploma
2 Passed GED/ certificate
of equivalency
3 Received Certificate of
Cal. H.S. Proficiency
7 Foreign secondary school diploma /Certificate
of Graduation
8 Received Associate’s Degree
9 Received Bachelor’s Degree or higher
6 Special admit student currently
enrolled in K-12th grades
5 Not a graduate of, and no longer
enrolled in high school
Yes, skip to part C.
No, list where you lived previously and the beginning and ending dates of your residence in that state or country.
No, but I am eligible for AB-540 status.
From
To
State/Country
What state do you consider as your permanent home?
If California, when did your present stay begin (Month/Day/Year)?
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
US Citizen
Permanent Immigrant
Temporary Resident / Amnesty
Refugee / Asylum
Student Visa (F-1 or M-1)
AB-540 Eligible (see Schedule for details)
A#
Applied/Issue Date
Residence Code
Residence Date
DATE
SIGNATURE OF STUDENT
To
From
17
Institutional
History (Coll)
College Last Attended
COLLEGE CODE
City
State
year
To
year
From
year
year
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