Admission Form
College of DuPage
College of DuPage • 425 Fawell Blvd., Glen Ellyn, Illinois 60137-6599 • (630) 942-2380, FAX (630) 790-2686 • www.cod.edu
PLEASE PRINT.
Social Security Number
—
—
(A valid Social Security number is required for Financial Aid and IRS reporting.)
Application Date __________________________
Date of Birth_______/_______/__________
month
day
year
Admission Term you wish to begin classes:
❑ Fall Term (August to December), 20___
❑ Spring Term (January to May), 20___
❑ Summer Term (May to August), 20___
Personal Information
Legal Name ______________________________________________________________________________________________________________
Last
First
Middle Initial
Prior Name _______________________________________________________________________________________________________________
Last
First
Middle Initial
Address __________________________________________________________________________________________________________________
Street Address
Apt. Number
City
State
ZIP
County
I have or will have lived at the above address at least 30 days prior to beginning of term.
Home Phone Number (
Cell Phone Number (
)
Phone 2 (optional) (
)
❑ yes ❑ no
)
Email address
Email address is required to create myACCESS account
Would you be interested in receiving communication via text message?
❑ yes ❑ no
Gender
❑
Male
❑
Female
Ethnicity
Are you Hispanic or Latino? (OR are you of Spanish origin?)
❑ Yes, Hispanic or Latino ❑ No, Non-Hispanic or Latino
Are you from one or more of the following racial groups? (Select all that apply.)
❑ American Indian or Alaska Native (AN)
❑ Asian (AS)
❑ Black or African American (BL)
❑ Native Hawaiian or Other Pacific Islander (HP) ❑ White (WH) ❑ Choose Not to Respond (NR)
Please identify your primary racial/ethnic group. (Select one.)
❑ Asian (1)
❑ White (5)
❑ American Indian or Alaska Native (2)
❑ Black or African American (3)
❑ Native Hawaiian or Other Pacific Islander (6) ❑ Choose Not to Respond
Are you a U.S. Citizen? ❑ yes ❑ no
Are you a Permanent Resident? ❑ yes ❑ no
❑ Hispanic or Latino (4)
If permanent resident, what is your country of citizenship? __________________________________________________________
Are you in the United States on a Visa – Nonresident Alien? ❑ yes ❑ no
If Yes, what is the visa type ____________________ Home country of origin _________________________________________
Educational Information
Highest education level completed at START of classes at College of DuPage:
❑ Unknown (U)
❑ Less than High School (L)
❑ High School Diploma (H)
❑ GED (G)
❑ Some College Credit (S)
❑ College Certificate (C)
Has anyone in your immediate family attended college?
❑ Associate Degree (A)
❑ Bachelor’s Degree (B)
❑ Master’s Degree (M)
❑ yes ❑ no ❑ unsure
❑ Professional Degree (P)
❑ Doctoral Degree (D)
❑ Other Degree (O)
Where did you first hear of College of DuPage?
❑ Alumni (ALUM)
❑ Business visit (BV)
❑ Community event (CE)
❑ COD staff/faculty (CODSF)
❑ Employer (EMP)
❑ High school visit (HSV)
❑ Family/friend (FF)
❑ Movie ad (MOVAD)
❑ High school counselor (HSC) ❑ Newspaper ad (NEWAD)
❑ Radio/TV ad (RTVAD)
❑ Web (WEB)
❑ Other (OTHR)
Are you planning on earning a degree or certificate at College of DuPage?
I plan on completing:
❑ an associate degree (AD)
❑ a certificate (CER)
❑ one or several courses, not pursuing a certificate or degree (NPD)
(continued on back)
Institutions Attended
High school currently attending _____________________________________________________ State ___________________________
(OR last high school attended)
Date graduated from high school? _____/______/_______
(month/day/year)
or Date you intend to graduate from high school? _____/______/_______
(month/day/year)
If GED, when was it earned? _____/______/_______
H.S. GPA _________________
(month/day/year)
Have you attended college before?
❑ yes ❑ no
ACT Score _________________
Have you earned college-level credit in the past?
❑ yes ❑ no
Most recent college or university attended _____________________________________________________________________________
Hours Completed ________________________________
College GPA ______________________________________________________
Educational Intent
Are you under 18 and plan to take college credit courses while still in high school?
What is your intended field of study as you enter COD?
❑ Associate of Arts (AA)
❑ Associate of Science (AS)
❑ Associate of Applied Science (AAS)
❑ Associate of General Studies (AGS)
❑ Associate of Engineering (AES)
❑ Associate of Fine Arts (AFA)
❑ yes ❑ no
❑ Certificate/Advanced Certificate (CERT)
❑ Non-Degree (ND) ❑ Undeclared (UD)
❑ Teaching Secondary Math Degree (AAT)
❑ Teaching Early Childhood Education (AAT-EC)
What is your primary goal for attending College of DuPage?
❑ To prepare for transfer to four-year
❑ To prepare for a future job immediately after ❑ Personal interest/self-improvement, not
college or university (TFCU)
attending the community college (PFJOB)
❑ Improve skills for present job (ISKILL)
❑ To prepare for the GED test or improve
career oriented (PINCO)
❑ Unknown/Other (UNKOW)
basic academic skills (PGED)
Indicate your intended MAJOR:
(from MAJOR Descriptions and CODE List) Example:
CODE:
MAJOR: Accounting
CODE: ACCOU.CER
Do you plan to attend:
❑ Full-time (12 credit hours or more) (F)
❑ Half-time (6 to 8 semester hours) (H) ❑ Overload (more than 18 semester hours) (O)
❑ Three-quarter time (9 to 11 semester hours) (P) ❑ Less than half-time (less than 6 semester hours) (L)
Do you plan to apply for financial aid?
❑ yes ❑ no
Are you a veteran of the U.S. military?
❑ yes ❑ no
Which was most influential in your decision to attend College of DuPage?
❑ Admissions Representative
❑
❑
❑
❑
(ADREP)
Alumni (AL)
Business visit (BV)
Community event (CE)
COD faculty/staff (CODF)
❑ Student (CODS)
❑ Employer (EMP)
❑ Friend/family (FRI)
❑ High school counselor (HSC)
❑ High school teacher (HST)
❑ High school visit (HSV)
❑ Location (LOC)
❑ Movie ad (MOVAD)
❑ Newspaper ad (AD)
❑ On-campus event (OCE)
❑ Program of study (PGM)
❑ Publication (CODPB)
❑ Radio/TV ad (RTVAD)
❑ Tuition cost (COST)
❑ Web (WEB)
❑ Other (OTHR)
❑ Advising Session
Additional Information
Activities in which you would like to participate:
❑ Adult Fast Track (AFT)
❑ Autismerica: ASD Social
❑ Cooperative Education/
Club (ASDSC)
❑
❑ Band (BAND)
❑ Baseball (BASEB)
❑
❑ Basketball Men’s (BASKM) ❑
❑ Basketball Women’s (BASKW) ❑
❑ Cross Country Men’s (CCM) ❑
❑ Cross Country Women’s (CCW) ❑
❑ Cheerleader/PomPom(CHEER) ❑
❑ Chorus (CHOR)
❑
❑ Concert Band (CONCB)
Internships (COOP)
Field and Experiential
Studies (FIELD)
Football (FOOTB)
Global Scholars (GLOBL)
Golf (GOLF)
Honors Program (HONOR)
International Education (INTED)
Jazz (JAZZ)
Latino Ethnic Awareness
Association (LEAA)
❑ Literary Magazine (LITER)
❑ Newspaper (Courier) (NEWSP)
❑ Orchestra (ORCH)
❑ Percussion Ensemble (PERCE)
❑ Student Social Events Planning
❑ Speech (SPEEC)
❑ Study Abroad (STAB)
❑ Student Ambassador (STAMB)
❑ Tennis Men’s (TENNM)
❑ Tennis Women’s (TENNW)
❑ Theater (THEAT)
(SAP)
❑ Service Learning (SERV)
❑ Track and Field Men’s (TRAKM)
❑ Student Government (SGOV) ❑ Track and Field Women’s
❑ Student Leadership (SLEAD)
(TRAKW)
❑ Soccer Men’s (SOCCM)
❑ Volleyball (VOLLY)
❑ Soccer Women’s (SOCCW) ❑ World Music Performance
❑ Softball (SOFTB)
(WORLD)
I certify that all of the information submitted is true and correct to the best of my knowledge. A $20 Admissions Recording fee (non-refundable) must accompany this form.
Signature
Date
ADM-12-10900(10/16/12)500