Student Information:
Please Print Clearly
Have you participated in a Pre-College Program at Queensborough Community College before? (Yes or No)
Student ID (OSIS) #
Social Security #
Date of Birth (M/D/Y)
Last Name
First Name
Middle Initial
Sex (M or F)
Address (with house #and apartment #)
City
State
Home Phone
Cell Phone
Zip
Email
Date Entered 9th Grade (M/D/Y)
Name of High School
Country of Origin/Race/Ethnicity:
ARE YOU A US CITIZEN? __YES __NO ARE YOU A PERMANENT RESIDENT? __YES __NO OTHER (Specify VISA type)_______
From what country or part of the world did you or your family originally come from ? (Check the box next to the name of the country or part of the
world with which you most identify.)
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China:Mainland (032)
China:Taiwan (148)
Hong Kong (170)
Korea (083)
India (070)
Vietman (178)
The Philippines (121)
Bangledesh (012)
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Israel (075)
Nigeria (113)
Peru (120)
Columbia (033)
Cuba (030)
Dominican Republic (045)
Ecuador (046)
Guyana (065)
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Haiti (066)
Jamaica (077)
Panama (117)
Puerto Rico (185)
Trinidad (153)
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England, Scotland, Wales (160)
 Germany (056)
 Barbados (013)
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Greece (060)
Ireland (074)
Italy (076)
Poland (122)
Russia (158)
Ukraine 223)
Other, specify_______
If you speak another language at home which one?
Ethnicity:
 African American/Black
 Latino/Hispanic
 American Indian or Alaskan Native
 Native Hawaiian or other Pacific Islander
 Asian
 White
 Asian Indian
 Other
Parent/Guardian Information: □Mr. □Ms. □Mrs.
Last Name
First Name
Address
City
State
Home Phone
Cell Phone
Work Phone
Email
Zip
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