In accordance with 20 U.S.C. § 1232g; 34 CFR Part 99, the Family Education Rights & Privacy Act (FERPA), the information provided will
Please print neatly, using black or blue ink
Do you have a Certificate of Completion, Associate’s Degree, Bachelor’s Degree or higher?
If yes, specify which (Certificate, Associate’s, Bachelor’s or higher):
First Name: Last Name: M.I.
Social Security #:
Home Address (Number, Street, Apt #)
STCC Student ID:
City, State, Zip Code:
Mailing Address, City, State, Zip Code (if different from Home Address):
Primary Phone (XXX-XXX-XXXX) Circle: home
( ) --
cell other Secondary Phone (XXX-XXX-XXXX) Circle: home
( ) --
School Email Address: @ s t u d e n t . s t c c . e d u
Personal Email Address:
Gender: Male Female Date of Birth (MM-DD-YYYY):
I am a U.S. Citizen or Permanent Resident: Yes No, Alien Registration Number:
(If no, please also provide a copy of your Green Card with this application)
English is my second language: Yes, No, My primary language is:
Select one or more ethnicities that you closely identify with:
Hispanic/Latino/Latina - The Federal Government refers to Hispanic as a person of Cuban, Mexican, Puerto Rican, South or Central
American or other Spanish culture or origin, regardless of race.
American Indian/Alaska Native - American Indian/Alaskan Native refers to a person having origins in any of the original peoples of
North and South America (including Central America), and who maintains tribal affiliation or community attachment.
Asian - Asian refers to a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent,
including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Native Hawaiian or Other Pacific Islander - Native Hawaiian or Other Pacific Islander refers to a person having origins in any of
the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Select the race you most closely identify with – Please select at least one:
Black or African American - Black or African American refers to a person having origins in any of the black racial groups of Africa.
Terms such as "Haitian" or "Negro" can be used in addition to "Black or African American.
White - White refers to a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.