hartnell college fall 2009

Part IV - To be completed by ALL applicantsHave you lived in California continuously since birth ?What state do you regard as your permanent home ?Yes NoIf California, when did your present stay begin ?m m d d y y(If you were born in CA and have not left, enter your birthdate)FOR OFFICE USE ONLY:1 = In Hartnell District 11 = Undoc. T.E.2 = Out of Hartnell District 12 = Docum. T.E.4 = USA NOT California5 = Foreign Student10 = K -12 StudentSpecial Support Services: HCC is committed to your educational success. Each area listed provides special services. Pleaseindicate those services that would benefit or interest youFA-Financial AidBS-Basic SkillsCC-Child CareCT-Course TutoringCW-CALWorksESL-Eng 2nd LangTS-Transfer ServicesEOPS-Ext Oppty PrgEA-Employment AssistanceDSPS-Disabled ServicesDo you receive VA benefits?Yes No Do you intend to apply for Financial Aid? Yes NoIntended Load: L-Less than Half Time (.5-5)H-Half Time (6)Emergency Information (Who to contact)NameT-Three Quarter Time (6-9) F-Full Time (12-15O-Overload (>15)# of Hours Employed per week:Phone number_____________________Institutions AttendedName of High School: ________________________________________ City: _______________From: _________________ To: _______________ Graduated? Yes No Year:_______Most recent college _________________________________________ City: _______________ State:______Years Attended from __________ To__________GraduateYesNoDegree:_______H.S. CODECOLLEGE CODEGraduation Types (check only those that apply)(0)(1)Not a Graduate/Not in High SchoolK-12th grade (Note: Students currentlyenrolled in high school or students underthe age of 18 and not a high schoolgraduate must also submit a "ConcurrentEnrollment Form".)(3)(4)(5)Received a High School DiplomaPassed GED/Cert of EquivalencyCertificate of Proficiency(7)(8)(10)Received Associate's DegreeReceived Bachelor's DegreeGraduate degree or higher(2)Enrolled in Adult School(6)Foreign Secondary School DiplomaNOTE: Degree earned does not necessarilyhave to be earned from the most recent collegeattended.FERPA Notification: Under notification of the Family Education Rights and Privacy Act, you may, at the time you actuallyenroll, direct the college to withhold release of directory information to persons not employed by the college. Directoryinformation includes student participation in officially recognized activities and sports including height and weight school ofgraduation of members of athletic teams; degrees, awards, and scholarships including President's and Dean's lists; names,addresses, phone number of graduates for publication in the College Alumni Directory.ALL APPLICANTS: Signature requiredA. I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS SUBMITTED BY ME ARE TRUE AND CORRECT. All materials submitted by mefor purposes of admission become the property of Hartnell Community College. I understand that falsification, withholding pertinent data, or failure to reportchanges in residence may result in dismissal.Student's Signature ______________________________________________________ Date ____________________________________________md:SHBC Rev. 9/30/05