CHABOT COLLEGE
CODE A MAJORS
25555 Hesperian Blvd
Hayward, CA 94545
(Use to complete Number 11 on the application)
AA-T DEGREE
2238
2239
1512
1513
2244
2245
0027
0028
1518
1519
Anthropology (CSU GE)
Anthropology (IGETC CSU)
Communication Studies (CSU GE)
Communication Studies (IGETC CSU)
Economics (CSU GE)
Economics (IGETC CSU)
Elementary Teacher Education (CSU GE)
Elementary Teacher Education (IGETC CSU)
English (CSU GE)
English (IGETC CSU)
AS-T DEGREE
0014
0015
0572
0575
Administration of Justice (CSU GE)
Administration of Justice (IGETC CSU)
Business Administration (CSU GE)
Business Administration (IGETC CSU)
AA DEGREE
2101
2230
0201
1002
1004
1005
1006
1043
2209
0402
0403
0703
1202
2105
2130
1508
0304
2203
2121
2120
Administration of Justice
Anthropology
Architecture
Art (Emph. in Ceramics)
Art (Emph. in Painting)
Art (Emph. in Sculpture)
Art (General)
Art History
Behavioral Science (General)
Biology
Biology (Emph. in Allied Health)
Computer Science (Emph. in Math)
Dental Hygiene
Early Childhood Development
Early Childhood Intervention
English (Emph. in Literature)
Environmental Studies
Ethnic Studies
Fire Prevention Inspector
Fire Technology
AS DEGREE
0501
0526
0210
0991
0987
0988
0989
0990
0986
0547
Accounting
Administrative Assistant
Architecture
Auto Technology (BMW Manufacture Training)
Auto Technology (Emph. in Chassis)
Auto Technology (Emph. in Drivetrain)
Auto Technology (Emph. in Engine Machining)
Auto Technology (Emph. in Engine Performance)
Auto Technology (Emph. in Maintenance)
Business (Emph. in Management)
CERTIFICATE OF ACHIEVEMENT
0525
0527
0809
0213
0974
0975
0976
0977
0978
0035
0564
0562
0810
0993
Accounting Technician
Administrative Assistant
Aquatics
Architecture Technology
Automotive Chassis Technology
Automotive Drivetrain Technology
Automotive Engine Machining (FA INELIGIBLE)
Automotive Engine Performance Technology
Automotive Maintenance Technology
Automotive Service Counsulting (FA INELIGIBLE)
Bookkeeping
Business-Transfer (FA INELIGIBLE)
Coaching
Consumer Technology
CERTIFICATE OF PROFICIENCY
0568
0821
0992
0751
0567
2218
0822
0016
0579
1025
2117
0570
Geography (CSU GE)
Geography (IGETC CSU)
Journalism (CSU GE)
Journalism (IGETC CSU)
Kinesiology (CSU GE)
Kinesiology (IGETC CSU)
Music (CSU GE)
Music (IGETC CSU)
Political Science (CSU GE)
Political Science (IGETC CSU)
2003
2004
2229
2234
1108
1109
1037
1041
1036
1040
Psychology (CSU GE)
Psychology (IGETC CSU)
Sociology (CSU GE)
Sociology (IGETC CSU)
Spanish (CSU GE)
Spanish (IGETC CSU)
Studio Arts (CSU GE)
Studio Arts (IGETC CSU)
Theatre Arts (CSU GE)
Theatre Arts (IGETC CSU)
2199
2133
1704
1705
Early Childhood Education (CSU GE)
Early Childhood Education (IGETC CSU)
Mathematics (CSU GE)
Mathematics (IGETC CSU)
1102
2205
1027
2215
4902
4903
0601
4919
4920
4923
4924
4932
4918
4921
4922
4925
4933
4943
4941
4939
French
Geography
Graphic Design
Human Services
Humanities (General)
International Studies
Journalism
Liberal Arts-Opt I Arts/Humanities
Liberal Arts-Opt I Comm. English Lang.
Liberal Arts-Opt I Social/Behavioral Sci.
Liberal Arts-Opt I Math/Science
Liberal Arts-Opt I Kinesiology/Wellness
Liberal Arts-Opt II Arts/Humanities (CSU GE)
Liberal Arts-Opt II Comm. English Lang. (CSU GE)
Liberal Arts-Opt II Social/Behavioral Sci. (CSU GE)
Liberal Arts-Opt II Math/Science (CSU GE)
Liberal Arts-Opt II Kinesiology/Wellness (CSU GE)
Liberal Arts-Opt III Arts/Humanities (IGETC CSU)
Liberal Arts-Opt III Comm. English Lang. (IGETC CSU)
Liberal Arts-Opt III Social/Behavioral Sci. (IGETC CSU)
4937
4935
4942
4940
4938
4936
4934
0603
1701
1204
1011
1206
1013
0804
0605
0519
2204
1105
1505
1008
Liberal Arts-Opt III Math/Science (IGETC CSU)
Liberal Arts-Opt III Kinesiology/Wellness (IGETC CSU)
Liberal Arts-Opt III Art/Humanities (IGETC UC)
Liberal Arts-Opt III Comm. English Lang. (IGETC UC)
Liberal Arts-Opt III Social/Behavioral Sci. (IGETC UC)
Liberal Arts-Opt III Math/Science (IGETC UC)
Liberal Arts-Opt III Kinesiology/Wellness (IGETC UC)
Mass Communications
Mathematics
Medical Assisting
Music
Nursing
Photography
Physical Education
Radio and Television Broadcasting
Real Estate
Social Science (General)
Spanish
Speech Communication
Theater Arts
0548
0549
1902
0759
0994
0922
0576
2129
2128
Business (Emph. in Marketing)
Business (General)
Chemistry
Computer Science (Emph. in Math)
Electronics Systems Technology
Engineering
Entrepreneurship
Fire Prevention Inspector
Fire Technology
2221
0935
0204
0939
1702
0941
0545
0750
0953
Human Services
Industrial Technology
Interior Design
Machine Tool Technology
Mathematics
Numerical Control
Retail Management
Software Specialist
Welding Technology
4927
2118
2131
2127
2126
0811
0563
0565
0036
4944
4928
0995
0208
0211
CSU General Education Breadth (FA INELIGIBLE)
Early Childhood Devel. (Basic Teacher)
Early Childhood Intervention Assistant
Fire Prevention Inspector
Fire Technology
Fitness Instructor
Health Care Management
Human Resources Assistant
Hybrid & Alternative Fuel Vehicles
IGETC (CSU GE) (FA INELIGIBLE)
IGETC (UC) (FA INELIGIBLE)
Industrial Electronic Technology
Interior Design
Kitchen and Bath Design
0940
0544
0538
1205
0942
0531
0520
0556
0552
0757
0812
0949
Machinist
Management
Marketing
Medical Assisting
Numerical Control Programmer (Machinist)
Office Technology
Real Estate
Retail Management
Small Business Management
Software Specialist
Sports Injury Care
Tool Maker
Office Technology
Personal Fitness Training Entrepreneurship
Photography
Project Management
Real Estate
Real Estate Entrepreneur
Retailing
Rhetoric
Sports Injury Care
Technical Design
Welding
(FA INELIGIBLE and NOT TRANSCRIPTED)
Administrative Assistant Entrepreneur
Aquatics
Automotive Technology Entrepreneur
Business Graphics
Business Skills
Case Management for Human Services
Coaching
Consumer Technology Entrepreneur
CPA Exam Prep: Fin. Acct. & Audit.
Digital Design
Early Child. Dev. (Associate Teacher)
Entrepreneurship
CERTIFICATE
1506
1024
2231
2232
0608
0609
0828
0829
1038
1039
2228
2233
0823
1520
2220
1015
0766
0767
0979
1521
2212
2211
1034
Fitness Instructor
Forensics
Geographic Information Systems
Graphic Design
ICT Cloud Infrastructure
ICT Cloud Services
Inspection and Pipe Welding
Interpersonal Communication
Multicultural Aware./Relations-Ser. Provider
Multicultural Aware./Self-Reflection
Music Industry Entrepreneur
0557
0830
1014
0574
0573
0569
0529
1522
0824
0030
0952
1019
1507
Illustration
Writing
4946
0099
0093
0000
(FA INELIGIBLE and NOT TRANSCRIPTED)
Creative Writing
Digital Media
Note: FA INELIGIBLE = FINANCIAL AID INELIGIBLE
OTHER
(NOT TRANSCRIPTED)
Liberal Arts and Sciences / Transfer
Other/Not Listed (FA INELIGIBLE)
Personal Development (FA INELIGIBLE)
Underclared (FA INELIGIBLE)
CODE B HIGH SCHOOLS
(To be used to complete Number 16 on the Application for Admission)
695978
073028
013022
013045
013058
013002
013006
013084
013117
014140
013300
073005 073112
074118
013209
013222
013003
384089
693280
073183
014168
011046
074238
073681
013267
013268
ABUNDANT LIFE CHRISTIAN
ACALANES
ALAMEDA
ALBANY
AMADOR
AMADOR VALLEY ADULT
AMERICAN
ARROYO
BERKELEY
BISHOP O’DOWD
BRENKWITZ CONT.
CALIFORNIA CAMPOLINDO CARONDELET
CASTLEMONT
CASTRO VALLEY
CASTRO VALLEY ADULT
CHINESE CENTRAL
CHINESE CHRISTIAN
CONCORD
CONCORDIA
CONLEY-CARABALLO
DE LA SALLE
DEL AMIGO
DEL VALLE
DEWEY
013270
013027
013274
013287
013014
013009
013310
014026
013313
014326
013339
013362
013352
013858
014414
013427
013430
013445
013452
013453
013466
013473
013479
013524
DUBLIN
EL RANCHO VERDE
EMERY
ENCINAL
FAR WEST
FOOTHILL
FREMONT ADULT
FREMONT CHRISTIAN
FREMONT SENIOR
GOLDEN GATE ACADEMY
GRANADA
HAYWARD
HAYWARD ADULT
EDEN AREA REGIONAL OCCUPATIONAL PROGRAM
HOLY NAMES
IRVINGTON
ISLAND
KENNEDY, JOHN F.
LINCOLN
LIVERMORE
LOGAN, JAMES
MARINA
McCLYMONDS
MISSION SAN JOSE
073436
014528
013531
073456
013541
013005
013463
013590
013605
013651
013028
013553
014048
013774
013758
013748
013781
013010
073650
014010
013794
014700
014715
014557
014735
013017
MONTE VISTA
MOREAU
MOUNT EDEN
MT. DIABLO
NEWARK ADULT
NEWARK MEMORIAL
NEW HAVEN ADULT
OAKLAND
OAKLAND TECHNICAL
PIEDMONT
PIEDMONT CONT.
REDWOOD ALTERNATIVE
REDWOOD CHRISTIAN
ROYAL SUNSET
SAN LEANDRO
SAN LEANDRO ADULT
SAN LORENZO
SAN LORENZO ADULT
SAN RAMON VALLEY
SHADY GROVE
SKYLINE SENIOR
ST. ELIZABETH
ST. JOSEPH’S, ALAMEDA
ST. JOSEPH’S NOTRE DAME
ST. MARY’S COLLEGE HIGH
STREET ACADEMY
013833
393800
013845
014065
013025
013039
013869
393030
TENNYSON
TRACY
VALLEY
VALLEY CHRISTIAN
VILLAGE
VINEYARD
WASHINGTON
WEST (MERRILL F.)
600000
800000
OUT OF STATE
OUT OF COUNTRY
CODE C LAST COLLEGE ATTENDED
(To be used to complete Number 17 on the Application for Admission)
CALIFORNIA COMMUNITY COLLEGES
015257
ALAMEDA
425213
ALLAN HANCOCK
345023
AMERICAN RIVER
195020
ANTELOPE VALLEY
155050
BAKERSFIELD
365074
BARSTOW
015236
BERKELEY CITY
045115
BUTTE
445076
CABRILLO
415062
CANADA
195175
CANYONS
195154
CERRITOS
155001 CERRO COSO
015235
CHABOT
365210
CHAFFEY
195177
CITRUS
305001
COASTLINE
555055
COLUMBIA
195196
COMPTON
075190
CONTRA COSTA
105523
COPPER MT.
345124
COSUMNES RIVER
365211
CRAFTON HILLS
405650
CUESTA
375250
CUYAMACA
305191
CYPRESS
435184
DE ANZA
335125
DESERT
075268
DIABLO VALLEY
195217
EAST LOS ANGELES
195225
EL CAMINO
435679
EVERGREEN VALLEY
325335
FEATHER RIVER
345125
FOLSOM LAKE
435227
FOOTHILL
105240
FRESNO
305240
FULLERTON
435263
GAVILAN
195257
GLENDALE
305282
GOLDEN WEST
375249
GROSSMONT
275129
HARTNELL
135570
IMPERIAL VALLEY
305580
IRVINE VALLEY
095001
LAKE TAHOE
015450
LANEY
015611
LAS POSITAS
185420
LASSEN
195337
LONG BEACH
195346
LOS ANGELES CITY
195365
LOS ANGELES HARBOR
195953
LOS ANGELES MISSION
195384
LOS ANGELES PIERCE
195387
LOS ANGELES SOUTHWEST
195390
LOS ANGELES TRADE-TECHNICAL
195396
LOS ANGELES VALLEY
075269
LOS MEDANOS
215060
MARIN
cp:9/10
235001
245475
015570
375509
435861
505500
275270
565320
195475
335403
285540
015610
305525
565321
335565
375542
195575
545364
125140
105523
195658
335687
345740
305579
365594
375663
375693
375300
385092
395670
435680
415151
305609
425560
195825
495690
305609
545071
455695
315730
475200
415711
485825
375807
155580
565741
365790
105131
195952
435860
585926
585925
MENDOCINO
MERCED
MERRITT
MIRA COSTA
MISSION
MODESTO
MONTEREY PENINSULA
MOORPARK
MT. SAN ANTONIO
MT. SAN JACINTO
NAPA VALLEY
OHLONE
ORANGE COAST
OXNARD
PALO VERDE
PALOMAR
PASADENA
PORTERVILLE
REDWOODS
REEDLEY
RIO HONDO
RIVERSIDE CITY
SACRAMENTO SADDLEBACK
SAN BERNARDINO
SAN DIEGO CITY
SAN DIEGO MESA
SAN DIEGO MIRAMAR
SAN FRANCISCO
SAN JOAQUIN DELTA
SAN JOSE
SAN MATEO
SANTA ANA
SANTA BARBARA
SANTA MONICA
SANTA ROSA
SANTIAGO CANYON
SEQUOIAS
SHASTA
SIERRA
SISKIYOUS
SKYLINE
SOLANO
SOUTHWESTERN
TAFT
VENTURA
VICTOR VALLEY
WEST HILLS
WEST LOS ANGELES
WEST VALLEY
WOODLAND
YUBA
CALIFORNIA STATE UNIVERSITY AND COLLEGES
156250
BAKERSFIELD
489150
CALIFORNIA MARITIME ACADEMY
601075
CHANNEL ISLANDS
046242
CHICO
196135
DOMINGUEZ HILLS
016178
016179
106260
106261
306106
126450
196131
196133
276001
196770
196140
346760
366184
376720
386796
436727
406145
376820
496710
506730
EAST BAY
EAST BAY EXTENSION
FRESNO
FRESNO EXT.
FULLERTON
HUMBOLDT
LONG BEACH
LOS ANGELES
MONTEREY BAY
NORTHRIDGE
POMONA
SACRAMENTO
SAN BERNARDINO
SAN DIEGO
SAN FRANCISCO
SAN JOSE
SAN LUIS OBISPO
SAN MARCOS
SONOMA
STANISLAUS
UNIVERSITY
017846
017851
577750
307781
197887
010269
337797
377837
387876
427677
447765
OF CALIFORNIA
BERKELEY
BERKELEY EXTENSION
DAVIS
IRVINE
LOS ANGELES
MERCED
RIVERSIDE
SAN DIEGO
SAN FRANCISCO
SANTA BARBARA
SANTA CRUZ
INDEPENDENT INSTITUTIONS
218097
DOMINICAN
010614
DEVRY UNIVE RSITY
278022
GOLDEN GATE
010318
HEALD, HAYWARD
018261
HOLY NAMES
018518
MILLS
418125
NOTRE DAME DE NAMUR
198625
POMONA
438830
SANTA CLARA
078624
SAINT MARY’S
438792
STANFORD
014593
UNIVERSITY OF PHOENIX
398840
UNIVERSITY OF THE PACIFIC
388892
UNIVERSITY OF SAN FRANCISCO
009748
CARRINGTON COLLEGE CALIFORNIA
6XXXXX
8XXXXX
OUT OF STATE
OUT OF COUNTRY
APPLICATION FOR ADMISSION
Submit to:
Submit to:
CHABOT-LAS POSITAS COMMUNITY COLLEGE DISTRICT
CHABOT COLLEGE
LAS POSITAS COLLEGE
25555 HESPERIAN BOULEVARD
3000 CAMPUS HILL DRIVE
LIVERMORE, CA 94551-9797 (925) 424-1500
HAYWARD, CA 94545-5001 (510) 723-6700
TERM FOR WHICH YOU ARE APPLYING
o
1
FALL
o
o
SPRING
COLLEGE (Select one)
SUMMER
2
SOCIAL SECURITY NUMBER
__ __ __ - __ __ - __ __ __ __
3
o
YEAR: ______________
DATE OF LAST ATTENDANCE AT THE COLLEGE
FULL LEGAL NAME Last Name (Print)
PREVIOUS NAME - Last Name (Print)
STATE
B
F
ME
N
W
BIRTHDATE
Example:
11
12
Month
NO
D
8
E
C
Day
2
__ __
7
6
7
__ __ __
E
C
__ __
2
7
6
SELECT A MAJOR CODE
{
HIGHEST EDUCATIONAL LEVEL AND YEAR
1 = Attending high school
during the semester for
which I am applying
——
2 = Attending adult school
)
ZIP CODE
__ __ __ __ __ - __ __ __ __
Asian
AC
Chinese
AI
Asian Indian
AJ
Japanese
AK
Korean
AL
Laotian
AM
Cambodian
AV
Vietnamese
AX
Other Asian
9
3
4
5
6
7
8
=
=
=
=
=
=
2
3
3A
4
5
6
6A
Day
=
=
=
=
=
=
=
DATE OF ISSUE OF U.S. VISA
__ __
Example: 2
7
Month
Year
__ __ __
D
E
Day
__ __
C
6
__ __
7
Example: 2
3 = Tagalog
13
HIGH SCHOOL LAST ATTENDED (use Code Sheet B)
D
E
C
Year
__ __
6
7
A
B
C
E
F
G
H
J
K
L
M
=
=
=
=
=
=
=
=
=
=
=
Transfer to a 4-year college after earning an A.A.degree
Transfer to a 4-year college without earning an A.A.degree
Obtain an associate’s degree (A.A. or A.S.)
Obtain an occupational certificate
Explore career interests, plans, and goals
Acquire new job skills
Enhance current employment opportunities/job skills
Educational development (intellectual, cultural)
Improve basic skills in English, reading or math
Complete credits for high school diploma
Undecided
YES
NO (If no, complete the box below.)
5 = Other
DATE OF HIGH SCHOOL DIPLOMA OR LAST HIGH SCHOOL OF ATTENDANCE
Month
Name
State
Month
__ __ __
WHAT IS YOUR PRINCIPAL EDUCATIONAL GOAL?
C = 20-29 hours per week
N = Don’t expect to work
4 = Arabic
7
EXPIRATION DATE
COUNTRY OF CITIZENSHIP
IS ENGLISH YOUR PRIMARY LANGUAGE? IF NOT, WHAT IS YOUR PRIMARY LANGUAGE?
2 = Spanish
Other
O
Other Non-White
X
Declined to State
Permanent Resident (Alien Number:_______________________________)
Temporary Resident - copy of work authorization required
Amnesty Applicant or Recipient
Refugee/Asylee (INS Numer_________________________________)
Student Visa (F-1 or M-1)
Other (Specify: ______________________________) (copy of visa required)
Undocumented
High school diploma
GED or Cert. of H.S. proficiency
Cert. of Calif. H.S. proficiency
Foreign secondary diploma/certificate
Associate degree
Bachelor’s degree or higher
A = 1-9 hours per week
B = 10-19 hours per week
D = 30-39 hours per week E = 40+ hours per week
X = Don’t know
Pacific Islander
PG
Guamanian
PH
Hawaiian
PS
Samoan
PX
Other Pacific Islander
IF YOU ARE NOT A U.S. CITIZEN, COMPLETE THE FOLLOWING:
NUMBER OF HOURS YOU EXPECT TO WORK THIS TERM:
City
(
APT. NUMBER
PORT OF ENTRY
Year awarded
16
)
Phone
7
(Use Code Sheet A)
1 = Chinese
(
WORK PHONE
__ __ __ __ __ - __ __ __ __
__ __
ENROLLMENT STATUS (student type)
1 = Attending college for the first time since high school
2 = Never attended this college, but have attended or am currently
attending another college
3 = Returning to this college after attending another college
4 = Returning to this college and have not attended any other college
Y = Attending high school during the term for which I am applying
15
HOME PHONE
ZIP CODE
Year
__ __
20
14
3
Middle Name
Hispanic
HM Mexican, Mexican American, Chicano
HR
Central American
HS
South American
HX
Other Hispanic
DATE YOUR PRESENT STAY IN CALIFORNIA BEGAN
Month
Day
Year
Example: D
9
Name
__ __ __
ARE YOU
A U.S. CITIZEN?
__ __
C
First Name (Print)
ETHNIC IDENTITY/ORIGINS (Select one)
African American/Black
Filipino
Middle Eastern
American Indian/Alaskan Native
White, Non-Hispanic
YES
10
5
Returning Student
Year
Middle Name
STATE
In case of emergency, contact:
New Student
First Name (Print)
CITY
FEMALE
E
MAILING ADDRESS (IF DIFFERENT)
NUMBER AND STREET
7
D
APT. NUMBER
CITY
6
__ __ __
Month
RESIDENCE ADDRESS (NOT A P.O. BOX)
NUMBER AND STREET
MALE
o
o
Las Positas
Example
E-MAIL ADDRESS
4
o
Chabot
Example:
__ __ __
D
E
C
Year
__ __
6
7
SCHEDULE
CR:9-07
17
COLLEGE LAST ATTENDED (Use Code Sheet C)
DATE HIGHEST COLLEGE DEGREE AWARDED
Month
College Name
State
Example:
Country
D
E
__ __
C
6
7
DEGREE EARNED
ASSOCIATE
LIST BELOW ALL COLLEGES ATTENDED (including Chabot and/or Las Positas):
COLLEGE OR UNIVERSITY
CITY AND STATE
OR FOREIGN COUNTRY
If no college attended, write “None”
18
Year
__ __ __
BACHELOR’S
MASTER’S
DATES OF ATTENDANCE
Month/Year
to
Month/Year
/
to
/
/
to
/
/
to
/
DOCTORATE
DEGREES EARNED
RESIDENCY INFORMATION - MUST BE COMPLETED
The information you furnish will be used to determine whether you qualify as a California resident. Nonresidents will be required to pay nonresident tuition. Generally, residency requires that you must have lived in California with the clear intent of becoming a permanent resident for
at least one year and a day prior to the first day of instruction for the term in which you are enrolling. The burden of proof to clearly demonstrate
both physical presence in California and intent to establish California residence lies with the student.
Documentation may include two of the following: California driver’s license or identification card, bank statement, voter registration, letters
from employers or governmental agencies, rent receipts, or transcripts from California schools. There are certain exceptions to this rule which
apply to military personnel and their dependents, or in the case of certain students below 19 years of age, etc. You may be required to supply additional information to determine your residency status. Such information might be evidence in accordance with Education Code Sections 68040
et sec.
ALL STUDENTS CLASSIFIED INCORRECTLY AS RESIDENTS ARE SUBJECT TO RECLASSIFICATION AND TO PAYMENT OF ALL NONRESIDENT FEES NOT PAID.
1. PLACE OF BIRTH_______________________________________________________________________________________________
City
State/Country
2. HAVE YOU LIVED IN CALIFORNIA CONTINUOUSLY SINCE BIRTH?
Yes
No
If Yes, skip to section 20.
3. WHAT STATE DO YOU REGARD AS YOUR PERMANENT HOME?____________________
HAVE YOU LIVED AT YOUR
PRESENT ADDRESS FOR
LESS THAN TWO YEARS?
Yes
DATE YOU BEGAN LIVING AT
YOUR PRESENT ADDRESS
No
Example:
IF YES, LIST THE ADDRESS(ES) WHERE YOU RESIDED FOR THE PAST TWO YEARS:
STREET ADDRESS
Day
CITY
__ __
2
FROM
STATE
7
Month
D
E
20
7
Yes
No
Yes
Yes
No
No
City/State
IF YOU ARE ON ACTIVE MILITARY DUTY OR A DEPENDENT OF A PERSON ON ACTIVE DUTY,
INDICATE THE DATE MILITARY SERVICE BEGAN IN CALIFORNIA
Are you considering applying for Veterans Benefits? Yes
No
Are you a dependent of a service-connect disabled or service-connected deceased veteran?
6
IF YES, IN WHAT YEAR?
Yes
No
Yes
No
Yes
No
Yes
No
Number and Street
Submit copy of orders, military I.D. card, or DD214 with application for admission
C
TO
COMPLETE THIS SECTION IF YOU ARE UNDER 19 YEARS OF AGE
Have you lived continuously for the past two (2) years with one or both of your parents or court appointed legal guardian?
If Yes, check one:
Both parents
Mother Father
Legal Guardian
Has the person(s) indicated above lived continuously for the past two (2) years in California?
Has the person(s) indicated above claimed you on their federal or state income tax for the past one (1) year?
Indicate their name(s) and address below:
19
__ __
Month/Year Month/Year
ANSWER EACH OF THE FOLLOWING QUESTIONS:
Have you registered to vote in a state other than California?
Have you petitioned for divorce in a state other than California?
Have you attended an out-of-state educational institution as a resident of that state?
Have you declared non-residence for California state income tax purposes?
Name(s)
Year
__ __ __
Example:
Yes
Day
Month
__ __
2
7
Year
__ __ __
D
E
C
__ __
6
7
No
STUDENT SIGNATURE
NOTE: Students applying for Nursing, Dental Hygiene, Paramedic, or the International Student (F-1 visa) programs must complete separate application
forms.
I hereby apply for admission to Chabot College and/or Las Positas College and certify under penalty of perjury that to the best of my knowledge,
ALL of the above statements are correct and complete. I also understand that willful omission or falsification or failure to report changes in residence may result in my dismissal from the college with forfeiture of credit.
Date______________________________________________ Signature_____________________________________________________
CR:9-07