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Palomar College Application for Admission.pdf

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					                                                                                      Palomar College Application for Admission
                     Palomar College Admissions                                                                        1140 W. Mission Rd.                                                    San Marcos, CA 92069
                                                                                         	       	       Not	           	                              	                           Special	    Special
                                                                                         	     Found	   Found	       Finish	                      Residence	                       Status	     Status




                                                                                                    BOXES ABOVE FOR OFFICE USE ONLY
                     Any	information	provided	on	this	form	is	maintained	for	student	record	purposes	and	for	reporting	to	state	and	federal	agencies.	The	information	you	
                     provide	is	voluntary	and	will	be	kept	confidential.	For	financial	aid	and	tax	reporting	purposes	you	must	provide	your	social	security	number,	your	major	
                     and	your	anticipated	graduation	date.	For	more	information,	see	the	Palomar	College	Catalog	under	Admissions	Policy.

                     Please	answer	the	questions	as	they	pertain	to	the	beginning	of	the	semester	for	which	you	are	applying.
                                                         .	 Legal	Name
                                                         	                               Last	                                           First	                                   M.I.	                     Prior

                                                         2.	 Have	you	ever	been	employed	by	Palomar	College?	❏	Yes	❏	No

                                                         3.	 Social	Security	Number	                                       -	             -	                        Palomar	I.D.	Number

                                                         4.	 Gender	(please	check)	                           ❏ Male	 ❏ Female
                                            M.I.




                                                         5.	 Citizenship	(proof	may	be	required)	(Please	check	appropriate	number.)

                                                               ❏	 .	 U.S.	citizen,	by	birth	or	naturalization	(naturalization	date:	          /	       /	                                                 )

                                                               ❏	 2.	 Not	a	U.S.	citizen,	hold	permanent	resident	visa,	date	issued:	               /	       /	                                                   .

                                                               ❏	 3.	 Not	a	U.S.	citizen,	amnesty	recipient,	date	issued:	            /	         /	        .

                                                               ❏	 4.	 Not	a	U.S.	citizen,	but	a	refugee,	parolee	or	asylee,	date	issued	            /	       /	                                                   .

                                                               ❏	 5.	 Not	a	U.S.	citizen,	hold	student	visa	(F-,	M-,	J-	or	J-2).
                                            First	




                                                               ❏	 6.	 Other,	not	a	U.S.	citizen,	hold	other	visa	                        or	visa	type	unknown.

                                                         6.	 Birthdate	                      /	          /                            Age                      Students	under	8	must	submit	school	Approval	
                                                         	           Mo.	                    Day	       Year                                                   Form	with	application	(including	consent	for	
                            Please Print




                                                                                                                                                               treatment	of	minor).
                                                         7.	 Ethnic	Background	(please	check	appropriate	box)	The	data	gathered	is	used	for	state	and	federal	reporting	
                                                         	   	   purposes.	This	question	is	voluntary	and	will	not	be	used	to	discriminate	for	admission	to	the	College.
                                                         	 ❏	 Asian	                         ❏	 Other	Asian	                           ❏	 American	Indian/Alaskan
BOXES	FOR	OFFICE	USE	ONLY




                                                         	 ❏	 Chinese	                       ❏	 Black	                                 ❏	 Guamanian
                                                         	 ❏	 Asian	Indian	                  ❏	 Filipino	                              ❏	 Hawaiian
                                                         	 ❏	 Japanese	                      ❏	 Hispanic	                              ❏	 Samoan
                                                         	 ❏	 Korean	                        ❏	 Mexican	                               ❏	 Other	Pacific	Island
                                                         	 ❏	 Laotian	                       ❏	 Central	American	                      ❏	 White
                                                         	 ❏	 Cambodian	                     ❏	 South	American	                        ❏	 Unknown
                                                         	 ❏	 Vietnamese	                    ❏	 Other	Hispanic	                        ❏	 Declined	to	state
                                            Last	Name	




                                                         8.				E-mail	address,	please	enter	here:	
                                                         							NOTE:	Reliable	Internet	access	and	email	address	REQUIRED	for	online	classes

                                                         9.				Military	Status	–	(Only	completed	by	active	military	persons,	veterans	discharged	within	the	last	year,	or	dependents	of	active	duty																																						
                                                         	     personnel.)
                                                         	
                                           Name




                                                                 Will	you	be	on	active	duty	in	the	armed	services	stationed	in	California	on	the	opening	day	of	the	semester	in	
                                                                 which	you	plan	to	enroll?							Yes		❏					No		❏
                                           	




                                                                 (if	“Yes”)	When	did	your	current	duty	in	California	begin?	____________________________________________

                                                                 Is	California	indicated	on	your	last	Leave	and	Earning	statement?			Yes	❏		Submit	your	last	LES.	                                                       No	❏	

                                                                 Were	you	discharged	from	the	Armed	Forces	within	the	last	year?			Yes	❏		Date	of	discharge	_______________
                                                                 Submit	DD24	        No	❏
                                                                 			 	
                                                                 Are	you	the	dependent	or	spouse	of	a	person	on	active	duty	in	the	armed	services	stationed	in	California	on	the	
                                                                 opening	day	of	the	semester	in	which	you	plan	to	enroll?	Yes	❏	 No	❏

                                                                 (If	“Yes”)	When	did	his/her	current	duty	in	California	begin?	_______________		Present	or	submit	copy	of	
                                                                 dependent	I.D.


                                                                                                                                     
0.	 Area	code	and	phone	number			(	                 )

.	 Address	while	attending	Palomar	
	(No	P.O.	Box)
	                Number	                            Street	                           Apt.	#	                    City	              Zip	Code


2.	 Mailing	address	(if	different	from	above)	

	   Number	                               Street	                          Apt.	#	                       City	                     Zip	Code




.	 Semester	you	plan	to	attend	(please	check	appropriate	box)
	   ❏	Summer	(June)	 ❏	Fall	(August)
	   ❏	Summer	&	Fall	(June	&	August)	       ❏	Spring	(January)

2.	 What	is	your	objective	while	attending	Palomar?	(please	check	appropriate	box)
	   ❏	AA	degree	           ❏	Certificate	      ❏	Transfer	to	4-year	institution	                ❏	Other
	    Please	enter	your	major	area	of	study	by	using	the	listing	in	the	class	schedule	or	posted	in	Admissions.	Please	enter	the	
     abbreviation	shown	next	to	the	actual	description.

	    (enter	abbreviation	here)	                                                      (e.g.	BUS-MGT)
	    	                                        (required)
	    If	none	of	the	above,	enter	“undecided.”

	    Enter	full	description	here




3.	 Enrollment	Status	(please	check	appropriate	box)
	   ❏	 Y.	 Currently	enrolled	in	a	grade	K-2.
	   ❏	 .	 New	(never	attended	any	college).
	   ❏	 2.	 New	Transfer	(attended	college	but	not	Palomar).
	   ❏	 3.	 Returning	Transfer	(attended	Palomar	but	last	attended	another	college).
	   ❏	 4.	 Returning	(attended	Palomar	but	not	last	semester).
	   ❏	 5.	 Continuing	(currently	enrolled	or	attended	Palomar	last	semester).


4.	 Last	high	school	attended?	Please	check	box,	if	school	is	listed	below:
     ❏ Borrego	Springs	(373044)             ❏ La	Costa	Canyon	(37300)                ❏ Rancho	Buena	Vista	(373072)
     ❏ Carlsbad	(373069)                    ❏ Mission	Hills	(00572)                  ❏ San	Dieguito	Academy	(37374)
     ❏ Center	City	(373744)                 ❏ Murrieta	(333052)                       ❏ San	Marcos	(373763)
     ❏ Eagles	Peak	Charter	(37325)         ❏ Mt.	Carmel	(373007)                     ❏ San	Pasqual	(373005)
     ❏ El	Camino	(37390)                   ❏ Oceanside	(373520)                      ❏ Temecula	Valley	(333037)
     ❏ Escondido	(373206)                   ❏ Orange	Glen	(37353)                    ❏ Torrey	Pines	(373003)
     ❏ Fallbrook	(37327)                   ❏ Poway	(373586)                          ❏ Valley	Center	(373)
     ❏ Guajome	Pk.	Acad	(373094)            ❏ Ramona	(373597)                         ❏ Vista	(373870)
     ❏ Julian	(37332)                      ❏ Rancho	Bernardo	(37308)
	    Name	and	location	of	high	school	if	not	listed	above.                                                               OFFICE USE ONLY


	               Name	                                          City	                              Co.	                     State

For	the	above	question,	in	what	year	did	you	receive	the	diploma,	certificate	or	degree.	If	none,	enter	the	last	year	attended.




                                                                       2
5.	 Last	college	or	university	attended?	Please	check	box,	if	school	is	listed	below:

	   ❏ CSU	Long	Beach	(963)	             ❏ National	University	(378850)	                ❏ UC	Irvine	(30778)
	   ❏ CSU	Los	Angeles	(9633)	            ❏ Saddleback	(305579)	                         ❏ UC	Los	Angeles	(97887)
	   ❏ CSU	San	Marcos	(376820)	             ❏ San	Diego	City	(375663)	                     ❏ UC	Riverside	(337797)
	   ❏ Chapman	(30848)	                    ❏ San	Diego	Mesa	(375693)	                     ❏ UC	San	Diego	(377837)
	   ❏ Grossmont	(375249)	                  ❏ San	Diego	Miramar	(375300)	                  ❏ University	of	San	Diego	(37855)
	   ❏ MiraCosta	(375509)	                  ❏ San	Diego	State	University	(376720)	         ❏ U.S.	International	University	(378058)
	   ❏ Mt.	San	Jacinto	(335403)	            ❏ Southwestern	(375807)
    Name	and	location	of	college	or	university,	if	not	listed	above:                    OFFICE USE ONLY


	             Name	                                                    City	               Co.	                    State
For	the	above	question,	in	what	year	did	you	receive	the	diploma,	certificate	or	degree.	If	none,	enter	the	last	year	attended.



    List	all	other	colleges	attended:
	

	              Name	                                                       City	           Co.	                    State

	              Name	                                                       City	           Co.	                    State


6.	 What	semester	do	you	plan	to	graduate	from	Palomar	College?			Spring			Summer			Fall			(please	circle)			Year	____
7.	 What	is	the	highest	level	of	education	you	have	achieved?	(please	check	appropriate	box)	(SB)
	   ❏	 000	 No	longer	in	high	school	and	not	a	high	school	graduate.
	   ❏	 00	 Currently	enrolled	in	K-2.
	   ❏	 200	 Currently	enrolled	in	Adult	School.
	   ❏	 300	 Received	a	high	school	diploma.
	   ❏	 400	 Passed	the	GED,	or	received	high	school	certificate	or	equivalency.
	   ❏	 500	 Received	certificate	of	high	school	proficiency	(C.H.S.P.E.).
	   ❏	 600	 Received	foreign	secondary	school	diploma/certificate.
	   ❏ xxx	 None
8.	 Higher	Education	Level	(SB)
	   ❏	 700	 Received	an	Associate	Degree.
	   ❏	 800	 Received	a	Bachelor	Degree	or	higher.
    ❏ xxx	 None
For	question	7	and	8,	in	what	year	did	you	receive	the	diploma,	certificate	or	degree.	If	none,	enter	the	last	year	attended.



9.	 What	is	your	immediate	educational	goal?	(please	check	appropriate	box)	(SB4)
	   ❏	 A.	 Obtain	an	A.A.	degree	and	transfer	to	a	4-year	institution.	❏	 I.	 Maintain	certificate	or	license	(e.g.	nursing,	real	estate).
	   ❏	 B.	 Transfer	to	a	4-year	institution	without	an	A.A.	degree.	 ❏	 J.	 Educational	development	(intellectual,	cultural).
	   ❏	 C.	 Obtain	a	2-year	associate’s	degree	without	transfer.	       ❏	 K.	 Improve	basic	skills	in	English,	reading	or	math.
	   ❏	 D.	 Obtain	a	2-year	vocational	degree	without	transfer.	        ❏	 L.	 Complete	credits	for	high	school	diploma	or	GED.
	   ❏	 E.	 Earn	a	vocational	certificate	without	transfer.	            ❏	 M.	 Undecided	on	goal.
	   ❏	 F.	 Discover/formulate	career	interests,	plans,	goals.	         ❏	 N.	 To	move	from	noncredit	coursework	to	credit	coursework.	
	   ❏	 G.	 Prepare	for	a	new	career	(acquire	job	skills).	             ❏	 O.	 4	year	college	student	taking	courses	to	meet	4-year	college		
	   ❏	 H.	 Advance	in	current	job/career	(update	job	skills).	         	  	 requirements.

0.	 Please	check	appropriate	box:
	    ❏	 I	speak,	read	and	write	English	most	of	the	time.
	    ❏	 I	speak,	read	and	write	another	language	most	of	the	time.
.	 Please	estimate	the	average	hours	per	week	of	employment	during	the	semester.	(please	check	appropriate	box)
	    ❏	 N=not	employed	 ❏	 A=-9	hours	 ❏	 B=0-9	hours	 ❏	 C=20-29	hours	 ❏	 D=30-39	hours	 ❏	 E=40+
2.	 What	was	your	high	school	grade	point	average?	(please	check	appropriate	box)
	    ❏	 A	(3.5	-	4.0)	     ❏	 B	(2.5	-	2.9)	        ❏	 Below	2.0
	    ❏	 B+	(3.0	-	3.4)	    ❏	 C	(2.0	-	2.4)
3.	Did	either	of	your	parents	graduate	from	a	four	year	college?	           ❏	Yes	 ❏	No	 ❏	Decline	to	state
                                                                       3
The	following	questions	are	optional	but	will	assist	Palomar	in	obtaining	institutional	grants	that	may	be	beneficial	to	all	students.

4.		What	is	your	mother’s	highest	level	of	education	(MEDU)
	    ❏	 Less	than	high	school
	    ❏	 High	school	graduate	or	GED
     ❏	 Some	College	
	    ❏	 Associate’s	degree
     ❏ Bachelor’s	degree
     ❏	 Graduate	work/professional	degree
	    ❏ Unknown
     ❏ Decline	to	state

5.		What	is	your	father’s	highest	level	of	education?	(FEDU)
	    ❏	 Less	than	high	school
	    ❏	 High	school	graduate	or	GED
     ❏	 Some	College	
	    ❏	 Associate’s	degree
     ❏ Bachelor’s	degree
     ❏	 Graduate	work/professional	degree
	    ❏ Unknown
     ❏ Decline	to	state

6.		Do	you	need	assistance	in	learning	how	to	read,	write	or	pronounce	words	in	English?	(LAST)
     ❏	 Yes
     ❏	 No
	    ❏ Decline	to	state

7.		Number	of	members	in	your	family/household	(the	people	who	live	in	your	home)?	(FAMS)
	    ❏	 One
     ❏	 Two	
	    ❏	 Three
     ❏ Four
     ❏	 Five
	    ❏ Six
     ❏ Seven
     ❏	 Eight	or	more
	    ❏ Decline	to	state

8.		What	is	your	annual	family/household	income?	(FAMI)
	    ❏	 A.	$5,35		or	less
     ❏	 B.	$5,36	to	$20,535
	    ❏	 C.	$20,536	to	$25,755
     ❏ D.	$25,756	to	$30,975
     ❏	 E.	$30,976	to	$36,95
	    ❏ F.		$36,96	to	$4,45
     ❏ G.	$4,46	to	$46,635
     ❏	 H.	$46,636	to	$5,855
     ❏	 I.		 $5,856	or	more	
	    ❏ Decline	to	state

19.		Many	students	fall	into	more	than	one	ethnic	and/or	racial	category.	We	need	to	find	out	how	many	of	our	students	have	Latino,	
     Hispanic,	or	Spanish	origin	or	heritage	as	part	of	their	background.		
     Please	let	us	know	which	category	best	reflects	your	ethnic	background?	(EBAK)
	    ❏ Latino,	Hispanic,	or	Spanish	(Cuban,	Mexican,	Puerto	Rican,	South	or	Central	American,	or	other	Spanish	culture	or	origin)
	    ❏ None	of	the	above

Note:		   By	identifying	yourself	as	having	”Latino,	Hispanic,	or	Spanish”	ethnic	origin	or	background,	you	are	not	excluding	your	racial		 	
	   	     identity	(Filipino,	White,	Black,	Asian,	Pacific	Islander)	or	other	heritage.

If	you	need	accommodation	for	testing	purposes,	please	notify	the	Disabled	Student	Services	office.
 	
                                                                      4
Name	                                                                                                                  Social	Security	Number	                              -	            -
	            Last	Name,	                                    First	                                             M.I.
PART 1 – ALL STUDENTS MUST ANSWER THE FOLLOWING TEN QUESTIONS
State	laws	regulate	admission	of	students	on	the	basis	of	legal	residence.	This	statement	is	a	certification	necessary	to	administer	the	laws.	If	additional	information	is	needed	to	determine	your	residence	
status,	you	will	be	required	to	complete	a	supplemental	residence	questionnaire	and/or	to	present	evidence	in	accordance	with	Educational	Code	Sections	68040	et	seq.	The	burden	of	proof	to	clearly	
demonstrate	both	physical	presence	in	California	and	intent	to	establish	California	residence	lies	with	the	student.


.	 Place	of	birth:
	                                                          City	                                                      State	or	Country

2.	 Where	have	you	resided	the	past	24	months?
	                                                                                                             From	                                       To
	                        (City)	                                                       (State)	                         (Month/Day/Year)	                        (Month/Day/Year)
	                                                                                                             From	                                       To
	                        (City)	                                                       (State)	                         (Month/Day/Year)	                        (Month/Day/Year)
	                                                                                                             From	                                       To
	                        (City)	                                                       (State)	                         (Month/Day/Year)	                        (Month/Day/Year)

3.	 Did	you	attend	a	California	high	school	for	3	years	and	earn	a	diploma	or	equivalent?														❏	Yes	                                                           ❏	No	
Complete	questions	4-0	about	yourself.	If	you	are	unmarried	and	under	9	years	of	age,	complete	questions	4-0		
about	your	parents.

	     NO	                                                                                                                                    YES	 If	yes,	what	year?

4.	  ❏	      Filed	personal	state	income	tax	to	another	state?	                                                                                ❏
5.		 ❏	      Voted	in	another	state?	                                                                                                          ❏
6.	 ❏	       Attended		an	out-of-state	education	institution	as	a	resident	of	that	state?	                                                     ❏
7.	 ❏	       Declared	residency	in	another	state	for	income	tax	purposes?	                                                                     ❏
8.	 ❏	       Petitioned	for	divorce	in	another	state?	                                                                                         ❏
9.	 ❏	       Had	a	valid	driver’s	license	in	another	state?	                                                                                   ❏
0.	 ❏	      Registered	a	vehicle	in	another	state?	                                                                                           ❏
PART 2 – IF YOU ARE UNDER 19 YEARS OF AGE WHEN CLASSES BEGIN – COMPLETE THE FOLLOWING
Give	names	and	permanent	legal	residence	for	the	following	persons.	If	deceased,	enter	word	“deceased.”
SHOW	ADDRESSES	TO	COVER	AT	LEAST	TWO	YEARS	(Legal/Permanent	Address	–	Do	not	use	P.	O.	Box	Number.)


Father’s	Name	                                                                                                                                           U.S.	Citizen	           ❏	Yes	 ❏	No

Current	Address
	                                   Number	                        Street	                         City	                           State	                      Zip	         Since	What	Date

Previous	Address
	                	                                     	                                    	                               	                        	                      Since	What	Date


Mother’s	Name	                                                                                                                                           U.S.	Citizen	           ❏Yes	 ❏	No

Current	Address
	                                   Number	                        Street	                         City	                           State	                      Zip	         Since	What	Date


Previous	Address	
	                	                                     	                                    	                               	                        	                      Since	What	Date

Your	Current	Address
	                                   Number	                        Street	                         City	                           State	                      Zip	         Since	What	Date


Previous	Address
	                		                                    	                                    	                               	                        	                      Since	What	Date


I	certify	that	the	statements	made	in	this	application	are	true	and	complete	to	the	best	of	my	knowledge.	I	understand	that	falsification,	withholding	
pertinent	data,	or	failure	to	report	changes	in	residence,	may	result	in	my	dismissal.	Palomar	College	maintains	directory	information	which	consists	
of	the	student	name,	address,	telephone	number,	and	enrollment	schedule.	If	you	do	not	want	information	disclosed	in	the	directory	please	notify	
the	Records	Office.


Student’s	Signature	                                                                                                                 Date

                                                                                                      5
PLEASE FOLD ALONG LINE, ATTACH POSTAGE AND MAIL TO:




         PALOMAR COLLEGE ADMISSIONS
            1140 WEST MISSION ROAD
             SAN MARCOS, CA 92069

				
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