Fillable Student Information Update (Eastern Florida State College)

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Student Information Update (Eastern Florida State College)

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Country of origin: US
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U.S.A. forms for Eastern Florida State College

BROWSE EASTERN FLORIDA STATE COLLEGE FORMS

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IMPORTANT: Complete this form if you have not taken a class in the past year.
If it has been two or more years s
ince you comple
te
d
a c
lass, you must submit an
App
licati
on
for
A
dmiss
ion.
Print clearly using black or blue ink only and sign. Incomplete forms will
be retu
rned.
You must complete a Residency Affidavit and submit supporting documentation
.
1.
Have you previously attended BCC or EFSC?
/
Yes, Last date attended
No
MM YYYY
2.
Social Security Number*
3.
4.
Last Name
First Name
Midd
le Name
5.
List any previous name(s) under which t
ranscripts
or
othe
r
records may
be
receiv
ed
.
6.
Mailing Address
Street Number and Name
City
State
Zip
7. Phone/Email
Home Phone
Cell Phone
Email Address
8.
Emergency Contact
Firs
t Name
Last Name
Relationship to Student
Phone Number
The following information is required by the U.S. Department of Education under Title IV of the Civil Rights Act of 1964 and the Title IX A
ct of the Educational Amendments
of 1972 to be used for reporting purposes. This information is voluntary. It will not be used in determining admission to Eastern Florida State College.
9.
Ethnicity Check one
Hispanic or Latino
Not Hispanic or Latino
10. Race
Check all that apply
American Indian or Alaskan
Native
Asian
Black or African Americ
an
Native Hawaiian or Other P
acific Islander
White
11.
Date of Birth
/ /
MM DD YYYY
12.
Gender
Male
Fem
ale
*Section 6050S of the Internal Revenue Code requires that all eligible educational institutions report the name, address, and TIN of any individual who is enrolled by the
institution for coursework leading toward a post-secondary degree, certificate or other recognized post-secondary educational credential. This IRS requirement makes
it necessary for colleges to collect the SSN of every student. A student may refuse to disclose his or her SSN to the college, but the IRS is then authorized to fine the
student in the amount of $50. All SSNs are protected by Federal regulations (FERPA) and are never released to unauthorized parties.
Florida Statute 119.071(5)(a) authorizes the collection, usage, and release of your social security number by EFSC. EFSC collects and uses
your SSN only for the
purpose of performing College duties and responsibilities. In an effort to protect your identity, EFSC will secure your SSN from unauthorized access and will not release
your SSN to unauthorized parties. EFSC will assign\RXDuQLTXH student/employee identification number. This unique ID is used for most associated purposes at EFSC.
STUDENT INFORMATION
UPDATE FORM
Office Use Only:
B
Admit Term:
Received by:
Received Date:
Apt #
SC139 R092313
Previous BCC/EFSC Student ID#
13.
I received a:
Standard High School Diploma
Special Diploma*
Certificate of Completion*
*
Students admitted with a special diploma or certificate of completion (except specific CPT-eligible certificates of
completio
n a state issues GED before pursuing an associate's degree or college credit courses.
I am
c
urrently
in
High S
chool
Expected graduation date:
MM/DD/YYYY
I rec
eived
a state issued General Ed
ucation Diploma (GED)
I completed a Home School High School equivalent program

Consult with Admissions for requir
ed documents
I am not a high school graduate
State where GED was earned
Date GED was earned
MM/DD/YYYY
Date earned
14. Did you attend another college or university?  Yes No
List in chronological order each college/university
you attended even if you withdrew or earned no credit. Please do not abbreviate the
institution name. Attach additional sheet if required. FINANCIAL AID WILL NOT BE AWARDED UNTIL ALL OFFICIAL TRANSCRIPTS ARE
RECEIVED AND EVALUATED.
Name of College/University
(Do not abbreviate)
City
State
Dates Attended
Type of
Degree
Earned
From To
15. Educational Objective
Degree Seeking:

Non Degree Seeking:
Transient Student
Brevard
County Teacher
Associate of Arts (AA)
Associate of Science (AS)
College Credit Certificate (CCC)
Applied Tech
nology Diploma (ATD)
Vocational Certificate (PSAV)
Personal Enrichment
Job related
Intended Major
Program Code
See Programs and Admissions Requirements sheet for choices
I am seeking admission to a EFSC Limited Access Program
Note: Each Limited Access Program has an additional application and may have an application fee; contact the
department or visit an Academic Advisor.
16.
Have you ever been convicted of a sexual offense which resulted in probation, community service or incarceration?
No If yes, you will be denied admission. A letter will be sent to your mailing address with further information.
APPLICATION AGREEMENT
I hereby apply for admission to Eastern Florida State College and certify that all information is accurate and complete to the best of my knowledge. If admitted to Eastern
Florida State College, I agree to abide by all the regulations of the College and the laws of the State of Florida. I certify that as a condition of my admission, I will not
engage in
the unlawful manufacture, distribution, dispensation, possession or use of a controlled substance during enrollment at Eastern Florida State College according to the
College’
s
Drug-Free Policy. I also understand that in order to take
courses
for credit or to receive credit for
courses
completed, a copy of my final, official high school transcript is required,
along with official transcripts from all
colleges
previously attended. I further agree to allow my
records
and test
scores
to be electronically
received
from other institutions and/or
transferred to the institution of my
choice. I agree to pay any costs associated with the collection of unpaid, delinquent or defaulted charges, including collection costs , attorney fees, and court costs.
I understand that my
admission
to the College may be revoked if it is demonstrated that I have committed any act of academic dishonesty.
Applicant’s Signature (Required to complete the application)
Date
Educational Background
High School Name
State
City
If foreign, list country
SC139 R092313
Yes
(Check one of the following)
Date completed:
MM/DD/YYYY
MM/DD/YYYY
List name, city, state, and country of the High School you last attended or graduated from.
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Student Information Update (Eastern Florida State College)

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Completed 24 July 2020

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