Fillable Printable City College of San Francisco Application Form for Admission
Fillable Printable City College of San Francisco Application Form for Admission
City College of San Francisco Application Form for Admission
CITY COLLEGE OF SAN FRANCISCO
APPLICATION FOR ADMISSION
C R E D I T D I V I S I O N
APPLICATION DATE
OFFICE OF ADMISSIONS & RECORDS • 50 PHELAN AVE. • ROOM E-107 • SAN FRANCISCO, CA 94112 • (415) 239-3285
Please provide ALL information requested on this form.
PERSONAL INFORMATION
1. Social Security Number ______ ______ ______-______ ______-______ ______ ______ ______
Be sure your Social Security Number is accurate as it is used as part of your permanent record. You will also be assigned a Student Identification Number.
2. Legal Name (Please Print)
Last Name _____________________________ First Name __________________________ Middle Name _________________
E-mail Address ______________________________________________________________________________________________
3. Previous Last Name Used at City College if Different From Current Last Name __________________________________
Previous First Name______________________________________ Previous Middle Name _______________________________
4. Term For Which You Are Applying q Fall q Spring q Summer Year ___________________________________
PERMANENT RESIDENCE ADDRESS (NOT A P.O. BOX)
5. Number and Street________________________________________________________________ Apt. Number ______________
City _________________________________________
State ______________________ Zip Code __________________________
Permanent Residence Phone (______) __________________________
Work Phone (______) ___________________________
MAILING ADDRESS (IF DIFFERENT FROM PERMANENT ADDRESS)
6. Number and Street________________________________________________________________ Apt. Number ______________
City _________________________________________
State ______________________ Zip Code __________________________
Permanent Residence Phone (______) __________________________
Work Phone (______) ___________________________
7. Gender q Male q Female q Option Not Listed 8. Date of Birth Month Day Year
___ ___ ___ ___ ___ ___
9. Ethnic Background (check one or more)
Are you Hispanic or Latino? q Yes q No
q 01 Hispanic, Latino
q 02 Mexican, Mexican-American, Chicano
q 03 Central American
q 04 South American
q 05 Hispanic Other
q 06 Asian Indian
q 07 Asian Chinese
q 08 Asian Japanese
q 09 Asian Korean
q 10 Asian Laotian
q 11 Asian Cambodian
q 12 Asian Vietnamese
q 13 Filipino
q 14 Asian Other
q 15 Black or African American
q 16 American Indian/Alaskan Native
q 17 Pacific Islander Guamanian
q 18 Pacific Islander Hawaiian
q 19 Pacific Islander Samoan
q 20 Pacific Islander Other
q 21 White
10.
Citizenship Status? (Check One Only)
q I am a U.S. Citizen (1)
Non-U.S. Citizen
q I am a permanent Resident Alien
Card Holder _____________(2)
q I am a Temporary Resident (3)
q I am a Refugee/Asylee (4)
q I am on a Student Visa (M-1 or F-1) __________ (5)
q Other Citizen Status ________________________ (6)
q I am a recipient of a B1, B2, or F2 Visa __________ (9)
Example 1 2 2 5 6 7
11. Major (Program of Study You Intend to Pursue) ______________________________ qqq
(Select a Major Code from the Major Code Sheet – Use Code Sheet “A”)
12. Enrollment Status ENTER APPROPRIATE NUMBER IN BOX q
1 Attending college for the first time since high school.
2 Never attended this college but have attended or are currently attending another college.
3 Returning to this college after attending another college.
4 Returning to this college and have not attended another college since last term here.
Y Attending high school during the term for which I am applying to this college.
Date of last attendance at CCSF – Semester: _________ Year: _________
13.
Educational Goal (You MUST check one of the Following Goals)
q Obtain an Associate Degree and Transfer to a 4-Year Institution (A)
q Transfer to a 4-Year Institution Without an Associate Degree (B)
q Obtain a 2-Year Associate’s Degree Without Transfer (C)
q Obtain a 2-Year Vocational Degree Without Transfer (D)
q Earn a Vocational Certificate Without Transfer (E)
q Discover/Formulate Career Interest, Plans and Goals (F)
q Prepare for a New Career (Acquire Job Skills) (G)
q Advance in Current Job/Career (Update Job Skills) (H)
q Maintain Certificate of License (e.g. Nursing, Real Estate) (I)
q Educational Development (Intellectual, Cultural) (J)
q Improve Basic Skills in English, Reading and/or Math (K)
q Complete Credits for High School Diploma or GED (L)
q Undecided on Educational Goal (M)
14.
Educational Status (Check Highest Level You Have Achieved)
q Earned a U.S. High School Diploma in ______ (3)
q Special Student Currently Enrolled in Grade 12 or Below (100)
q Not a High School Graduate, Currently Enrolled in Adult School (200)
q Passed the GED or Received a Certificate of H.S. Equivalency in ______ (4)
q Earned a California H.S. Proficiency Certificate in ______ (5)
q Earned a Foreign Secondary Diploma or Certificate of Graduation in ______ (6)
q Earned a U.S. Associate Degree in ______ (7)
q Earned a U.S. Bachelor’s or Higher Degree in ______ (8)
q Not a Graduate of, and No Longer Enrolled in High School (000)
q Unknown/Unreported (XXX)
15. Number of Hours You Expect to Work This Term in Addition to Your Studies:
Example: A
q A. = 1-9 Hours Per Week B. = 10-19 Hours Per Week C. = 20-29 Hours Per Week D. = 30-39 Hours Per Week
E. = 40+ Hours Per Week N. = Do Not Expect to Work X. = Do Not Know At This Time
16. Is English Your Primary Language? YES q NO q
17. In case of emergency, contact ____________________________________________ (______) ________________________
Name Phone
18. What High School Did You Attend Last?
Code Number: qqqqqq (Use High School Code Sheet Column)
Name of High School:________________________________________________________________________________________
City:____________________________________________________ State:______________ Month Day Year
Graduation Date ___ ___ ___ ___ ___ ___
Example 1 2 2 5 6 7
Provide information on all school(s) you attended in grades 9 - 12
School City State
Dates
From-Month/Year
Dates
To-Month/Year
EMERGENCY CONTACT
EDUCATION INFORMATION
19. What College Did You Attend Last?
Code Number: qqqqqq (Use College Code Sheet Column)
Name of College:________________________________________________________________________________________
City:_________________________________Country:________________________________ Month Day Year
Degree Earned: qAssociate (AA) qBachelors (BA) qMasters (MA) qDoctorate (PHD) qNot Applicable
Date Highest College Degree Awarded ___ ___ ___ ___ ___ ___
Example 1 2 2 5 6 7
20. List Below all the Colleges Attended (including City College of San Francisco), including the College Listed in Question 19.
COLLEGE/UNIVERSITY
If No College, Write “None”
CITY AND STATE
or Foreign Country
DATES OF ATTENDANCE
Month/Year to Month/Year
DEGREES EARNED
21. City College of San Francisco is committed to assisting you in achieving your educational goals. Each area listed below
provides special services. Please indicate the services that you will utilize. (Please check all that apply)
q Would like to receive information about money for college (1)
q Child Care (2)
q Disabled Student Programs and Services (3)
q Transfer Services (4)
q Employment Assistance (5)
q Basic Skills (6)
q Tutoring (7)
q English as a Second Language (ESL) (8)
q Extended Opportunity Programs and
q Services (EOPS) (9)
q Bilingual Assistance (10)
22. City College receives additional assistance to support our educational programs and financial aid for students. How much we receive is depen-
dent upon certain information we provide our students, their background, income levels, and experiences. Please complete this section to help us
receive our “fair share.” All information is voluntary and is strictly confidential.
Would you classify yourself as economically disadvantaged? _____Yes _____No
What is your annual household income
____ Below $23,750 ____ $23,751-$27,150 ____ $27,151-$30,550 ____ $30,551-$33,950
____ $33,951-$36,650 ____ $36,651-$39,350 ____ $39,351-$42,050 ____ $42,051-$44,800
____ Over $44,800
How many dependents are in your family including yourself? (please check one)
___ 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ 6 ___ 6 ___ 8 ___ 9+
Are you a recipient of CALWORKS (formerly AFDC)? _____Yes _____No
Are you a recipient of the Workforce Investment Act (WIA)? _____Yes _____No
Are you a recipient of Supplemental Security Income Program (SSI)? _____Yes _____No
Are you a recipient of Temporary Assistance for Needy Families (TANF)? _____Yes _____No
Are you a recipient of General Assistance Program (GA)? _____Yes _____No
Are you a recipient of Section 8 Housing? _____Yes _____No
Are you a recipient of any other form of economic public assistance? _____Yes _____No
Please specify _____________________________________________
Are you a single parent? _____Yes _____No
NON-DISCRIMINATION POLICY
All programs and activities offered by City College of San Francisco shall be performed in a manner which is free of discrimination on the basis of
race, color national origin, ancestry, religion, creed, sex, pregnancy, marital status, sexual orientation, disability or veteran status.
CALIFORNIA RESIDENCY CERTIFICATION
The information you provide in the following section will be used to determine your residency in California, Nonresidents of California will be assessed nonresident
tuition at the time of enrollment.
In general, to qualify as a California resident, you must have resided in California with the clear intent of making California your permanent State of residence
for a minimum of one year and one day prior to the first day of instruction for the term in which you are enrolling. There are certain exceptions to this California
regulation which apply to military personnel and their dependents, or in the case of certain students below the age of 19 years.
You may submit two pieces of documentation to verify your California residence, e.g. California Drivers license, California Identification Card, bank statement,
voter registration card, letter from employer or government agencies, rent receipts, transcipts from California schools, etc.
Continued on back
q Career Planning (11)
q Student Health (12)
q Reentry Services (13)
q Gay, Lesbian, Bisexual Studies Department or
q Queer Services (14)
q Latino Services (15)
q African American Services (16)
q Homeless Services (17)
q Honors Program (18)
q I am interested in becoming a teacher (19)
q None of the Above (0)
1. THIS SECTION MUST BE COMPLETED BY ALL STUDENTS
Date you began living at your present address _______________ _______________ _______________
Month Day Year
If you have lived at your present address for less than two years, please list previous address(es) below:
Street Address City State Month/Year to Month/Year
According to State Law (section 54012, (b) subsection (f) of section 54024) each of the following questions must be answered:
If Yes, In What Year?
YEAR
Have you registered to vote in a state OTHER than California? q Yes q No ________________
Have you petitioned for a divorce in a state OTHER than California? q Yes q No ________________
Have you attended an out-of-state educational institution as a resident of that state? q Yes q No ________________
Have you declared non-residence for California state income tax purposes? q Yes q No ________________
2. THIS SECTION MUST BE COMPLETED ABOUT YOUR PARENT(S) OR GUARDIAN(S) IF YOU ARE UNMARRIED
AND UNDER THE AGE OF 19 YEARS.
Name of Legal Guardian: ____________________________________________________________________________________
Last First Middle
Relationship To You: q Father q Mother q Guardian
Answer the following for your Legal Guardian whether your parent(s) or other person(s)
Please Specify Your Guardian’s Citizenship of Visa Status:
q U.S. Citizen q Permanent Resident of U.S. with Immigration Adjustment Date: _____ _____ - _____ _____ - _____ _____
Month Day Year
Other Visa Status (please Specify):______________________________________________________________________________
Guardian’s Legal Address(es) for the Past Two Years
Street Address City State
When Did Your Legal Guardian(s) Present Stay in California Begin? _____ _____ - _____ _____ - _____ _____
Month Day Year
According to State Law (section 54012, (b) subsection (f) of section 54024) each of the following questions must be answered:
If Yes, In What Year?
Have your parent(s) or guardian(s) registered to vote in a state OTHER than California? q Yes q No ________________
Have your parent(s) or guardian(s) petitioned for a divorce in a state OTHER than California? q Yes q No ________________
Have your parent(s) or guardian(s) attended an out-of-state educational institution as a resident of that state? q Yes q No ________________
Have your parent(s) or guardian(s) declared non-residence for California state income tax purposes? q Yes q No ________________
YEAR
From To
Month/Year Month/Year
3. THIS SECTION TO BE COMPLETED BY MILITARY PERSONNEL AND THEIR DEPENDENTS ONLY.
Are you a member of the military? q Yes
Give date military service began in California _______ _______ _______
Month Day Year
Are you a dependent of a person on military active duty? q Yes
Give date military service began in California _______ _______ _______
Month Day Year
Please submit copy of Military Orders, Military I.D. Card or DD214 with this application.
IMPORTANT: Students classified incorrectly by the college as residents of California are subject to reclassification and
are responsible for payment of nonresident tuition.
TO BE SIGNED BY ALL STUDENTS
I declare under penalty of perjury that the statements submitted by me in connection with determination of California residence are true
and correct. All materials submitted by me for purposes of admission become the property of City College of San Francisco. I understand
that falsification, withholding pertinent data, or failure to report changes in residence may result in District action and full payment of all
applicable fees/tuition.
Student’s Signature ___________________________________________________________________________________ Date: __________________
FOR OFFICE USE ONLY
RESD-CD AH/HOLD REASON:
EXEMPT ENTD DATE
