APPLICATION FOR ADMISSION

LOS ANGELES COMMUNITY COLLEGE DISTRICT

1. Student Identification Number
(Leave blank unless you have previously been assigned a
Student Identification Number)

The social security number will no longer be used as primary

student identifier for students per Civil Code 1798.85. Student
Information System (SIS) will generate an identification number
for each student who is new to LACCD. Leave blank if you have
not been assigned a SID by the district.

_____________________________________________________
Last

First

Middle Initial

List other names you have used. If none, check box:

_____________________________________________________
Last

First

Middle Initial

_______________________________________________________________________
Number
Street
Apt. No.
_______________________________________________________________________
City
State
Zip Code

Students are required by law to provide their Social Security

Number, which will be used for reporting to the federal
government under the Taxpayer Relief Act of 1997 and for
financial aid verification. If you do not have a Social Security
number, or if you do not wish to use it, please leave blank.

I have lived at this address since: ____________________________________________________

Month
Day
Year

9. If you have lived at your present address fewer than two years, list previous address(es)

6. This application is for:

City/State

FROM: Mo/Yr

TO: Mo/Yr

__________________________________________________________________________________
City/State

FROM: Mo/Yr

Spring

7. Sex

Winter

Female

Summer

Male

Year __________
8. Birth Date
Month

Age

Day

Year

13. Contact Information

__________________________________________________________________________________
Number/Street/Apt. No.

If you are a returning student and have been previously assigned

an Alternate Identification Number by the district, please
complete. Otherwise leave blank.

Fall
4. Legal Address/Residence (Do not use P.O. Box or Business Address)

2. Social Security Number

Number/Street/Apt. No.

Please type or print clearly in black ink

5. Alternate Identification Number

3. Legal Name

E-mail: ________________________________________________________________
Primary Telephone: (________)
Area Code

TO: Mo/Yr

_____________________________________
Number

10. Mailing Address (if different from Legal Address given above)

14. Place of Birth

____________________________________________________________________________________________
Number/Street/Apt. No.
City/State
Zip Code

_________________________________________________________________
City
State or Foreign Country

15. Full name of the most recent High School you attended
11. My present stay in California began on: ____________________________________________
Month
Are any of the following on active military duty? (Please check all that apply)

Yourself

Spouse

Day

Year

__________________________________________________________
Name of High School

__________________________________________________________

Parents

City

12. 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)

State or Foreign Country

16. Last College attended. If none, check box:

___________________________________________________________
Name of College

Dates Attended

* Registered to vote in a state other than California? ...

Yes

No

If yes, what year?

___________

* Filed a legal action in a state other than California? .....

Yes

No

If yes, what year?

___________

___________________________________________________________

* Attended a non-California college/university as a resident of that state?

Yes

No

If yes, what year?

__________

City/State/Foreign Country

* Filed as a Non-Resident for California State Income Tax Purposes? . . Yes

No

If yes, what year?

__________

The LACCD is made up of the following schools. Please check ONE school.

City
Southwest
OFFICE
USE
ONLY

East
Trade Tech

Residence

Harbor
Valley

Mission
West LA

Matriculation

Pierce
ITV

Degree Awarded

17. I am a citizen of __________________________________________

Country
18. If you are not a United States Citizen, please circle and complete:
2. Permanent Resident Alien
______________________________
3. Temporary Resident Alien
Permanent Resident or Visa Number
4. Refugee, Asylee
5. Student Visa (F-1 or M-1 visa)
__________________________
6. Other (Specify): ________________ Issue/Adjustment Date
7. Visitor Visa (B-1 or B-2 visa)

High School

CONTINUE ON OTHER SIDE

College

Concurrent

19. Complete this question only if you are under 19 and have never been married.
Name of Parent or Legal Guardian: ___________________________________________________

Father Mother Legal Guardian Other ____________________

U.S. Citizen Permanent Resident Alien Other ____________________

Relationship to you:
Is the person a:

If a Permanent Resident Alien, enter A-Number and date of issue:

Current residence of this person:

__________________

___________________

From: __________ To: PRESENT

Month/Year

State

20. Ethnic Identity (*) Please enter number in box

10
11
12
13
14
15
16
19

=
=
=
=
=
=
=
=

Chinese
Japanese
Korean
Laotian
Cambodian
Vietnamese
Indian Sub-Continent
Other Asian

20
30
40
41
42
49
50

= Black, African-American
= Filipino
= Mexican, Chicano,
Mexican-American
= Central American
= South American
= Other Hispanic
= Caucasian, White

=
=
=
=

English
Armenian
Chinese
Farsi

5
6
7
8

=
=
=
=

Filipino
Japanese
Korean
Russian

9
10
11

60
70
71
72
79
80
90

=
=
=
=
=
=
=

American Indian, Alaskan Native

Pacific Islander; Samoan
Pacific Islander; Hawaiian
Pacific Islander; Guamanian
Other Pacific Islander
Other Non-White
Decline to state

= Spanish
= Vietnamese
= Other language ______________________________

22. What is your main educational goal? Please enter number in box
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

=
=
=
=
=
=
=
=
=
=
=
=
=
=
=

1
2
3
4
5
6
7
8
9

=
=
=
=
=
=
=
=
=

Earned a U.S. High School diploma (or will earn one before college semester begins)
Enrolled in grade 12 or below when college semester begins
Not a High School graduate, currently enrolled in adult school
Not a High School graduate, last attended High School
Passed the GED or received a certificate of H.S. equivalency
Number
Earned California High School Proficiency Certificate
Earned a Foreign Secondary diploma or certificate of graduation
Earned an Associate degree
Earned a Bachelors or higher degree
Year

25. Enrollment Status: Please enter number in box

21. What is your primary language? (*) Please enter number in box
1
2
3
4

24. Highest Education Status: Please enter number and year in boxes below

Prepare for a new career (acquire new job skills)

Advance in current job/career (update job skills)
Discover/develop career interests, plans and goals
Obtain a two-year vocational degree without transfer
Obtain a two-year Associate degree without transfer
Obtain a vocational certificate without transfer
Obtain a Bachelors degree after completing an Associates degree
Obtain a Bachelors degree without completing an Associates degree
Maintain certificate or license (e.g. Nursing, Real Estate)
Improve basic skills in English, reading or math
Complete credits for high school diploma or GED
Personal development (intellectual, cultural)
Undecided on goal
To move from noncredit coursework to credit coursework
Complete 4 year college requirements

1
2
3
4
5

=
=
=
=
=

First time college student

First time at this college, after attending another college
Returning to this college, after attending another college
Returning to this college, without having attended another college
Enrolling in this college, while attending school in the 12th or lower grade

26. College Units or degree completed by first day of this term

Please enter number in box
1
2
3

= 0 units
= 1 to 15
= 16 to 29

4
5
6

= 30 to 59
= 60 or more units, no degree
= A.A., A.S., B.A., B.S. or higher degree

27. Veteran (Leave blank, unless you are a veteran)

Were you honorably discharged from the U.S. Armed Forces?

Yes No

If Yes, date you were discharged: Month ______________

Day _______

Year ________

28. Student Information -- Permission to Release

TYPES OF STUDENT INFORMATION: According to the Los Angeles Community College District (1)
Directory Information: Includes your name; city of residence; participation in officially recognized activities and
sports; weight and height of athletic team members; dates of attendance; degrees and awards received; and the
most recent previous educational institution attended. (2) College Foundation Information: Includes your name,
address, and telephone number. 3) Four-year College Information: Includes your name, address, and telephone
number. 4) Military Recruiting Information: Includes Directory information plus address, telephone number,
date of birth, and major field of study.
I do not permit the college to release directory information
---------------------------------------------------------------------------------------------------------------------(Leave blank if you want information on LACCD Foundation scholarships, grants, and
networking opportunities)
I do not permit the release of information to the College Foundation
---------------------------------------------------------------------------------------------------------------------I do not permit the release of information to four-year colleges
I do not permit the release of information to the military
You may change your Directory Release at any time by completing a Release of Directory Information form and
returning it to the Admissions Office.

23. Special Services (*)

The Los Angeles Community College District is committed to increasing your educational success. Each area listed below provides
special services. Please indicate those services that interest you.
1.
6.
Financial Aid
Information regarding special services and/or accommodations for students with
2.
disabilities may be obtained from the Disabled Student Programs (DSPS) Office.
Child Care
7.
Are you from a low income family and in need of special counseling, tutoring, and/or
3.
Tutoring
4.
Transfer Assistance
financial aid assistance? Yes No
5.
8.
Employment
I am a former or current Foster Youth and am interested in financial aid
Assistance
and/or other benefits & services available to Foster Youth.

NON-DISCRIMINATION POLICY
All programs and activities of the Los Angeles Community College District shall be operated in a manner which is
free of discrimination on the basis of race, color, national origin, ancestry, religion, creed, sex, pregnancy, maritial
status, sexual orientation, age, handicap or veterans status (Reference: Board Rule 1202)
In order to ensure the proper handling of all civil rights matters, each college in the District has its own
Affirmative Action Representative, Title IX/Sex-Equity Coordinator, Section 504 Coordinator of Handicap
Programs, and an Ombudsperson. Direct initial inquiries to the Office of Diversity Programs at (213) 891-2000.

(*) NOTICE TO STUDENTS: Your responses to questions marked by this symbol will be used to provide you with information

29. Certification

on college programs and services and/or for statistical purposes only. Refusal to provide this information will not be used to deny
admission to the college or any of its programs.

I declare under penalty of perjury that all information on this form is correct. I understand that falsifying or
withholding information required on this form shall constitute grounds for dismissal.

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 Education Code sectoins 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.

REQUIRED
SIGNATURE ________________________________________________________ Date ______________
Revised: 10/2008