San Juan College Center for Workforce Development
Application for Admission
This Application is for Provisional/Non-Degree applicants only.
1)
Name:
Last First Middle
2)
Mailing Address:
Street/Box# City State Zip Code
3)
Are you a United States citizen?
□ Yes □ No
If “No”, Country of Citizenship:
(You must attach a copy of your current visa)
4)
Phone Number :
(Area Code) Home # (Area Code) Cell # (Area Code) Work #
5)
SS / ID Number:
(SS # must be entered for first time students – ID number will be assigned to use after that)
7)
Indicate any other names which may appear on your academic records:
6)
Birth Date:
EMERGENCY CONTACT INFORMATION - REQUIRED
Emergency Contact Name Relationship to Student Phone Number
Class Attending
□ CWD
Center for Workforce Development
Signature and Statement of Understanding
• It is the policy of San Juan College not to discriminate on the basis of sex, disability, race, color, religion, or national or ethnic origin
in its admission policy, financial aid, or other school administered programs. This policy is enforced by federal law under the Title IX
of the Education Amendments of 1972, Title VI of the Civil Rights Act of 1964, and Section 504 of the Rehabilitation Act of 1973.
Additionally, SJC grants the same tuition or state-funded financial aid to all persons in compliance with SB 582 (2005).
I AUTHORIZE San Juan College [including Center for Workforce Development (CWD) to release the above
information to my employer (or potential employer), AND I release San Juan College from any future liability
related to the release of this information.
Signature of Applicant Date
Company I work for:
Company
Address:
E:mail
address
click to sign
signature
click to edit
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