Pre­Unit Name:

Worksheet 2 Date:

Canyon County College

ADMISSION APPLICATION

YEAR ______ (check one) ___FALL ___SPRING ___SUMMER

INSTRUCTIONS: Type or print. Answer every question by filling in appropriate

boxes or writing information required. Failure to do so will delay your registration.

1. ________________________ ___________________ ________________

Last Name First Name Middle Name

2. ________________ 3. Date of Birth ____/____/____ ___ 4. _____-____-_____

Mother’s Maiden Name Mo Day Year Age Social Security Number

5. (____) _____-_______ 6. Place of Birth ________________________ 7. Sex (check one)

Area Code Telephone Number City, State or Foreign Country ___Male ___Female

8. CURRENT ADDRESS
___________________________________ _________________________ _____ _____________
Number and Street / Apt # City State Zip

9. WHEN DID YOUR PRESENT STAY IN CALIFORNIA BEGIN?______ /______ /______

Mo Day Year
List previous residence if current address is less than 2 years.
____________________ / ________ ________ to ________
City State Mo/Yr Mo/Yr
____________________ / ________ ________ to ________
City State Mo/Yr Mo/Yr
____________________ / ________ ________ to ________
City State Mo/Yr Mo/Yr

10. WHAT IS YOUR EDUCATIONAL GOAL?

(check one only) ___Personal development
___Vocational Certificate ___Improve basic skills in English, Reading, or Math
___BA/BS Degree after earning Associate Degree ___Formulate career interests, plans and goals
___Maintain certificate or license (e.g. Nursing, Real ___Complete credit for High School Diploma
Estate, Fire, etc.) ___Advance in current career; obtain promotion
___Associate Degree ___Prepare for a new career
___Education Development (intellectual, cultural) ___Undecided on goal

Heinle & Heinle © 2002
Stand Out 4 Activity Bank
 Pre­Unit Name:
Worksheet 2 Date:

11. WHAT IS THE HIGHEST LEVEL OF EDUCATION (BELOW COLLEGE) YOU HAVE ACHIEVED?
(check one only)
____ High School Diploma
____ GED
____ Certificate of Equivalency
____ Proficiency Exam
____ Certificate of Completion
____ Foreign Diploma
____ Not H.S. grad and not attending H.S.

12. IS ENGLISH THE LANGUAGE YOU WRITE AND SPEAK MOST FREQUENTLY?
____ Yes ____ No

13. ETHNIC BACKGROUND ( check one only)

____ Alaskan Native ____ Hispanic – Mexican, Mexican-American, Chicano
____ American Indian ____ Hispanic – South American
____ Asian – Chinese ____ Other Hispanic
____ Asian – Japanese ____ Laotian
____ Asian – Korean ____ Pacific Islander
____ Other Asian ____ Vietnamese
____ Black, Non-Hispanic ____ White, Non-Hispanic
____ Cambodian ____ Other
____ Filipino ____ Decline to state
____ Hispanic – Central American

14. DO YOU WANT INFORMATION REGARDING THE FOLLOWING SERVICES? ( check each service desired)
____ Physical Disabilities ____ Child Care ____ Communication Disabilities
____ Financial Aid ____ Finding Employment ____ Learning Disabilities
____ Tutoring ____ Veterans Benefits

I certify that the statements made by me are true and complete to the best of my knowledge.

____________________________________ ____________________________________
Signature Date

Heinle & Heinle © 2002
Stand Out 4 Activity Bank