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Spring Summer 2010 - SUNY Orange

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Personal Data Sheet forNon-Degree Seeking StudentsHigh school graduates and persons holding high school equivalency diplomasmay enroll in up to 11.5 credits, or less, a semester without making formalapplication for admission to the college.Individuals who do not possess a high school diploma or GED, see theAdmissions Office. DO NOT COMPLETE THIS FORM.www.sunyorange.eduLAST SEMESTER IN WHICH YOUTOOK A <strong>SUNY</strong> ORANGE CREDITCOURSE:FALL ..................... 20_____SPRING .................. 20_____SUMMER ................. 20_____NO PRIOR CREDIT COURSES _____LAST FIRST MIDDLE INITIAL MAIDEN NAMELEGAL ADDRESS CITY STATE ZIP FROM TO OTHER NAMES USEDLASTFIRSTPREVIOUS ADDRESS ( IF AT ABOVE ADDRESS LESS THAN 2 YRS ) NY COUNTY (OR STATE) OF LEGALRESIDENCYLOCAL ADDRESS (IF DIFFERENT FROM CURRENT LEGAL ADDRESS)ALL - SELECT ONE OR MORE: 01 WHITE 02 BLACK 04 ASIANHOME ( )CELL ( )WORK ( )SOCIAL SECURITY # (OPTIONAL) 05 AMERICAN INDIAN / NATIVE ALASKAN 08 NATIVE HAWAIIAN / PACIFIC ISLANDER(NOTE: DUE TO NEW GOVERNMENTAL REPORTING REQUIREMENTS, PERSONS WHO AREHISPANIC/LATINO MUST RESPOND TO THE ABOVE AND THEN COMPLETE THEFOLLOWING SECTION BELOW)-----------------------------------------------------------------------------------------------------------------------------------------ALL - ETHNICITY: ARE YOU HISPANIC / LATINO? YES NOIF YES, IS YOUR BACKGROUND? (YOU MUST SELECT ONLY ONE, IF HISPANIC/LATINO) : CENTRAL AMERICAN DOMINICAN MEXICAN PUERTO RICAN SOUTH AMERICAN OTHER HISPANIC/LATINOCITIZEN OF U.S. YES NOBIRTHDATE (MANDATORY)/ /_____ / ______ / _______SEX MALE FEMALEIS YOUR GOAL TO RECEIVE A DEGREEOR CERTIFICATE? YES NOHAVE YOU RECEIVED A DEGREE FROM <strong>SUNY</strong> ORANGE? YES NOIF YES:DATEDEGREEI WORK EACH WEEK: NOT EMPLOYED LESS THAN 20 HRS BETWEEN 20 AND 34 HRS 35 HRS OR OVERIN CASE OF EMERGENCY, CONTACT (GIVE NAME)NAME OF HIGH SCHOOL OR STATE ISSUING HIGH SCHOOL EQUIVALENCY (GED)NAME CITY STATEHOME ( )CELL ( )WORK ( )YEAR OF H.S. GRADUATION OR GED(MANDATORY)ALL OF THE INFORMATION PROVIDED IS TRUE AND COMPLETEDATESIGNATUREREV. October 10, 2008For Internal Use Only A# ___________________45

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