Fillable FINAL WLPrereq 8.29.14

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FINAL WLPrereq 8.29.14

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INTERCULTURAL/ INTERNATIONAL STUDIES DIVISION: WORLD LANGUAGES
De Anza College World Language Prerequisite Clearance Form
(For pre-requisite courses) Rev. 9/30/14
Instructions: Complete this intake form and submit it, preferably by e-mail, to the designated
faculty member along with applicable grade documentation (e.g., official or unofficial transcript(s),
test scores, final grade reports, certificates, diplomas). Your placement results will be e-mailed to
the address you provide below.
Please print neatly or type. Date: _______________________________ Quarter: _____________________
Student Name: _____________________________________________________________________________________________
Last First Middle
Campus Wide ID: __________________________ Student E-mail Address:____________________________________
Phone #: _______________________________ CRN (Course Registration Number)*: __________________________
(Number of the course you would like to enroll in)
*CRN is required for the Assessment Office/IIS Division to submit your clearance in the system.
1. Which language do you intend to enroll in? (Only one language per intake form)
French Italian Mandarin Sign Language
German Japanese Persian Spanish
Hindi Korean Russian Vietnamese
2. In which language level do you intend to enroll?
First Year (Elementary)
Second Year (Intermediate)
1. Level One (First Quarter)
4. Level Four (First Quarter)
2. Level Two (Second Quarter)
5. Level Five (Second Quarter)
3. Level Three (Third Quarter)
6. Level Six (Third Quarter)
3. Have you studied or are you currently studying this language in high school?
No. (Go to question #4.)
Yes. Please Specify: for how many years?
1 2 3 4 (Honors) 5 (Advanced Placement)
Please specify how long since your most recent high school class in this language.
Currently Enrolled 1 quarter 2 quarters 3 quarters 1+years: ______(please specify)
4. Have you studied this language in college?
No. (Go to question #5.)
Yes. Please specify how many quarters and/or semesters:
Quarters: 1 2 3 4 5 6
Semesters: 1 2 3 4 5 6
Please specify how long since your most recent college class in this language:
Currently Enrolled 1 quarter 2 quarters 3 quarters 1+years: _____(please specify)
5. Have you ever studied this language in a country other than the United States?
No. (Go to question #6.)
Yes. Please specify:
Name of country/countries: ___________________________________________________________
Duration of program or schooling: ____________________________________________________
Language level(s): ______________________________________________________________________
How long since this language experience? ____________________________________________
6. Do you use or have you used this language for job-related purposes?
No. (Go to question #7.)
Yes. Please describe the nature of the job (e.g., healthcare, customer service), frequency of
language use (e.g., daily, occasional, rare), and extent of language interactions (e.g., with
co-workers, customers, patients, over the phone, face-to-face, in written
correspondence).
Specify any specialized language training completed to achieve (language) proficiency in
your area of expertise (e.g., military, medical, legal, business, social work):
If you’re no longer using this language on the job please specify how long it has been
since you last did:
7. Have you ever taken a formal placement exam or a proficiency test in this language? (e.g., AP
exam in high school, ACTFL test, military or job-related certification exam).
No. (Go to question #8.)
Yes. Please describe and provide documentation of dates and scores, if available:
8. Are you a native speaker of this language or were you raised/currently live in a household in
which this language was/is used on a regular basis?
No. (If you answer “No”, this completes your application.)
Yes. Please answer 1-2 below:
1. Check all applicable types of language schooling and/or informal language
exposure that you have received.
Bilingual education in the United States (e.g., elementary school):
Grade levels: _____________________________________________________________________
Dates: ____________________________________________________________________________
Name of program and/or name of school: ____________________________________
INTERCULTURAL/ INTERNATIONAL STUDIES DIVISION: WORLD LANGUAGES
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FINAL WLPrereq 8.29.14

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Completed 9 June 2020

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