Application For Admission - Los Angeles Community College District
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C
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OS
NGELES
OMMUNITY
OLLEGE
ISTRICT
APPLICATION FOR ADMISSION
1. Student Identification Number
3. Legal Name
5. This Application is for
Leave blank unless you have previously been assigned a
_____________________________________________________
Fall
Winter
Spring
Summer
Student Identification Number
Last
First
Middle Initial
Non-Credit Only
Year __________
8
8
.
.
The social security number will no longer be used as primary
List other names you have used
If none, check box:
student identifier for students per Civil Code 1798.85. Student
____________________________________________________
Information System (SIS) will generate an identification number
6. Birth Date:
for each student who is new to LACCD. Leave blank if you have
Last
First
Middle Initial
Month/ Day/Year
not been assigned a SID by the district.
2. Social Security Number
4. Legal Address/Residence (Do not use P.O. Box or Business Address)
Age ________
Female
Male
7. Gender
_______________________________________________________________________
Number
Street
Apt. No.
Students are required by law to provide their Social Security
_______________________________________________________________________
Contact Information (print clearly)
8.
Number, which will be used for reporting to the federal
City
State
Zip Code
government under the Taxpayer Relief Act of 1997 and for
E-mail:
financial aid verification. If you do not have a Social Security
I have lived at this address since: ____________________________________________________
Number, or if you do not wish to use it, please leave blank.
Phone:
Month
Day
Year
9. If you have lived at your present address fewer than two years, list previous address(es)
15. (a.) I am a citizen of ____________________________________________
Country
____________________________________________________________________________________________________
(b.) If you are not a United States Citizen, please circle and complete:
Number/Street/Apt. No.
City/State
FROM: Mo/Yr
TO: Mo/Yr
(c.)
2. Permanent Resident Alien
______________________________
____________________________________________________________________________________________________
3. Temporary Resident Alien
Permanent Resident or Visa Number
Number/Street/Apt. No.
City/State
FROM: Mo/Yr
TO: Mo/Yr
4. Refugee, Asylee
10. Mailing Address (if different from Legal Address given above)
5. Student Visa (F-1 or M-1 visa)
______________________________
6. Other (Specify): ________________
Issue/Adjustment Date
________________________________________________________________________________________
7. Visitor Visa (B-1 or B-2 visa)
Number/Street/Apt. No.
City/State
Zip Code
11. Full name of the most recent High School you attended
16. The questions below must be answered by every applicant
.
__________________________________________________________
At any time in the past two years have you: (If you are under 19, answer for your parents)
* Registered to vote in a state other than California? ……………
No
Yes If yes, what year? _______
Name of High School
* Filed a legal action in a state other than California? …….……..
No
Yes If yes, what year? _______
* Attended a non-California college/university as a resident of that state? No
Yes If yes, what year?_______
__________________________________________________________________________
No
Yes If yes, what year? _______
City
State or Foreign Country
* Filed as a Non-Resident for California State Income Tax Purposes?
12
Last College attended. If none, check this box:
.
17. Complete this question only if you are under 19 and have never been married.
__________________________________________________________
_
Name of Parent or Legal Guardian: _________________________________________________
Name of College
Dates Attended
Relationship to you: □Father □Mother □ Legal Guardian □ Other ______________________
Is the person a: □U.S. Citizen □Permanent Resident Alien □ Other _____________________
City
State/Foreign Country
Degree Awarded
If a Permanent Resident Alien, enter “A-Number” and date of issue: ______________________
Current residence of this person: _____________________ From: ___________ To: PRESENT
13. My present stay in California began on:
State
Month/Year
Month
Day
Year
18. Ethnic Identity (*)
(If you were born in CA and have never lived in another state, please enter your date of birth)
Are you Hispanic or Latino?
Yes
No If yes, check all that apply:
14. Place of Birth
A = Mexican, Mexican/American, Chicano B = Central American C = South American D = Hispanic, Other
What is your race? Check one or more:
________________________________________________________________________________________
E = Asian Indian
J = Asian Cambodia
P = Pacific Islander Guamanian S = Pacific Islander, Other
City
State or Foreign Country
F = Asian Chinese
K = Asian Vietnamese Q = Pacific Islander Hawaiian T = Caucasian, White
G = Asian Japanese L = Filipino
R = Pacific Islander Samoan
U = Black, African- American
H = Asian Korean
M = Asian Other
I = Asian Laotian
O = American Indian, Alaskan/Native
Office
Matriculation
Partial Exempt.
Use Only:
Status:
Check one}: ENGL
Processed By
Date
Residence Code
Engl., Math & Orien.
EXEMPT
ENL/ESL
MATH
NON-EXEMPT
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