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Application Page

Application Page

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Published by John Brown

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Published by: John Brown on Nov 25, 2009
Copyright:Attribution Non-commercial

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11/24/2009

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73
Fall Semester 2009
5. BIRTHDATE:
_________________
________
6. MALE FEMALE
RETURNING TO COASTLINENEW STUDENT /
LastFirstMiddle
15. Would you like information regarding services for the following disabilities? (mark all that apply):13. ARE YOU HISPANIC or LATINO? Yes No14. WHAT IS YOUR RACE/ETHNICITY? (check one or more)8. CITIZENSHIP (CHECK ONE)
1 U.S. Citizen2 Permanent Resident3 Temporary Resident/Amnesty4 Reugee/Asylee5 Student Visa (with an F-1 or M-1 visa)6 Other Status X Status Unknown
A# _____________________________________Date Issued _________________Date Expires_____________
1. NAME:
____________________________________________________________________________________
3.
___________________________________
List Prior Last Names Used
Hearing Learning Speech Mobility or Orthopedic Health Impairment Severe Visual Impairment
OFFICE USE ONLY RC
The social security number is required or Financial Aid recipients, to generate a 1098T orm or the Hope Tax Credit and to expedite student requests totranser ofcial school documents. You are not required to submit it or any other reason. All students will be issued a student identifcation number or usewithin the Coast Community College District.
2. CURRENT ADDRESSOF RESIDENCE: _________________________________________________________________________________________________________
Number & StreetApt. No.City StateZipNumber & StreetMo/Yr to Mo/YrStateCity
IF UNDER 19, PARENTS CURRENT ADDRESS:
Number & StreetApt. No.
(If different from residence)
Zip
3. MAILING ADDRESS:
City State
12. WHEN DID YOUR PRESENT STAY IN CALIFORNIA BEGIN?
Month_______________ Day_____________ Year__________
I Less Than 2 Years, List Previous Address and Dates or Those 2 Years
HAVE YOU AT ANY TIME IN THE PAST TWO YEARS (OR IF YOU ARE UNDER 19, YOUR PARENTS):
Address _________________________________________________________________City ______________________________________ State ______________ Mo/Yr to Mo/Yr ____________________
Registered to vote in a state
other than
Caliornia? NO YES I yes, what year? ______________________________Petitioned or divorce in a state
other than
Caliornia? NO YES I yes, what year? ______________________________Attended an out o state institution as a resident o that
other
state? NO YES I yes, what year? ______________________________Declared nonresidence or Caliornia state income tax purposes? NO YES I yes, what year? ______________________________
Address _________________________________________________________________City ______________________________________ State ______________ Mo/Yr to Mo/Yr ____________________
4. SOCIAL SECURITY NUMBER:
PLEASE PRINT CLEARLY
DATE LAST ATTENDED:
STSV-Application 5/09
 
Asian OtherBlack or Arican AmericanAmerican Indian/Alaskan NativeGuamanianAsian IndianChinese JapaneseKoreanLaotianCambodia VietnameseFilipinoMexican, Mexican American, ChicanoCentral AmericanSouth AmericanHispanic OtherHawaiianSamoanPacifc Islander OtherWhite
Month/ Day /Year
Age:
 /
7. TELEPHONE: (Home) (______)____________________ Work/Cell (_______)___________________ EMAIL: ____________________________
Zip
COASTLINE COMMUNITY COLLEGE
APPLICATION TO REGISTER
This application is for:
Fall 2009Spring/IntersessionSummer ONLY
11460 Warner AvenueFountain Valley, CA 92708
CCCD Student ID #:_________________
11. ARE YOU A SINGLE PARENT WITH DEPENDENT CHILDREN?
 YES NO
10. MARK ANY WHO ARE IN THE ACTIVE MILITARY:
Yoursel Your Parent (FMD) Your Spouse (SMD) None
9. BIRTHPLACE:
City __________________________________________________________________________ State _______________________ Country _____________________________________

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