Palomar College
Bridges to the Future Program
Application Form
Full Name (First, MI, Last): __________________________________Gender: ________ DOB________________
Address______________________________________________________________________________________
City, State & Zip Code__________________________________________________________________________
E-mail address:_______________________________Phone number(s) include area code: ___________________
Date started college (MM/DD/YY):
Major: ___________________________________
Do you plan to obtain an AA degree before transfer? (Y/N):___ College GPA: _______________
Anticipated 4-yr institution: _________________
Desired ultimate degree (circle one): Associates
Doctorate
Combined M.D./PhD
Anticipated Major at 4-yr inst: ___________
Baccalaureate
Masters
Research Doctorate
Clinical
Other professional degree
Anticipated transfer date __________High School from which you graduated:
Are you legally eligible for employment in the United States?* (Y/N): _____
Are you a citizen or a non-citizen national?* (Y/N): _____
Student ID # ____________________
*
If accepted to the program you will be required to submit proof of your legal right to work in the United States. In addition, the Bridges program
requires that participating students be either citizens or non-citizen nationals. If you do not fit either of these two classifications, you will be unable to
participate in the program.
Please check the box that best describes your ethnicity.
1
2
3
4
5
6
7
8
Asian
Chinese
Asian Indian
Japanese
Korean
Laotian
Cambodian
Vietnamese
9
10
11
12
13
14
15
16
Other Asian
Black
Filipino
Hispanic
Mexican
Central American
South American
Other Hispanic
17
18
19
20
21
22
23
24
American Indian/Alaskan
Guamanian
Hawaiian
Samoan
Other Pacific Island
White
Unknown
Declined to State
Please attach the following materials: APPLICATION DEADLINE EACH YEAR: JULY 31
1. Unofficial transcripts to confirm good academic standing
2. Personal statement, including career aspirations
3. Two letters of recommendation. At least one letter must address your strength as an applicant for this program;
at least one letter must be from a science teacher.
To the best of my knowledge, the information I am supplying is accurate.
______________________
Printed Name
Return completed application to:
______________________________
Signature
________
Date
Dan Sourbeer, Bridges Coordinator
Palomar College
1140 W. Mission Rd.
San Marcos, CA 92069
Direct questions to: Dan Sourbeer (760) 744-1150 ext 2775 or dsourbeer@palomar.edu
Fn=116095902
Rev Aug 03