SSU Extended Education: Undergraduate Application for Special Sessions Degree Programs
FOR OFFICE USE ONLY:
Entry Date:
Empl ID:
Check #:
By:
App #:
BEGIN APPLICATION HERE: There is no online application form. Please fill in, print, then mail or fax to: SSU Extended Education, 1801 E. Cotati Ave, Rohnert Park, CA 94928. (Response to each item is mandatory unless otherwise indicated.)
Attach $55 (U.S.) application fee payable to SSU. The fee is nonrefundable and may not be tranferred to another term. Please note, there is no fee waiver available for Special Sessions degree programs.
3. Please check the program to which you are applying:
Fall Spring
Year
If you do not have a social security number at the time you file the application, leave the item blank; the campus will assign a substitute number.
Use of Social Security Number: SSU uses the social security number as the identifier for student records maintained in your association with the campus and, if needed, to help collect debts owed the university. Applicants are required to include their social security number in designated places on applications for admission pursuant to authority contained in Title 5, California Code of Regulations, Section 41201.
If you have previously applied to or attended this campus, please list:
7a. Phones
Check preferred number
Home Phone
Daytime Phone
Cell Phone
10. Name of intended major: Liberal Studies
11. How many total transferable semester units will you have completed at time of entry/reentry in the CSU? (estimate)
12. Degree Objective:
BA
13. GPA for all transferable undergraduate college work (estimate):
15. Please list all colleges attended, even if no work was completed. Begin with the last institution attended. Attach a separate sheet if you need more space. For units in progress and planned, see the next list below.
Institution
Location
From (mm/yy)
To (mm/yy)
Transferable units completed
Degree received
Date to be received
Office Use Only
Please send two official, sealed transcripts from all colleges attended, including Summer and Extension units, to SSU Extended Education, 1801 E. Cotati Ave., Rohnert Park, CA 94928-3609. On the envelope, include "Attention to:" and use the appropriate name from the list below:
16. List below college courses in which you are currently enrolled and additional courses you plan to complete (including summer school) before entering the program. Attach a separate sheet if more space is needed.
Courses in Progress:
Institution
Term/Year
Dept. Course No. and Title
Unit Value
Courses Planned:
Institution
Term/Year
Dept. Course No. and Title
Unit Value
Institution
Term/Year
Dept Course No. and Title
Unit Value
Grade (if in progress or planned, use IP)
Oral Comm.
Written Comm.
Critical Thinking
Quant. Reasoning
High School Diploma GED
18b.State Issued by:
18c. Date issued:
21. Enter your ethnic/racial identity. To conform with the new guidelines of the Federal Office of Management and Budget, the CSU must collect from applicants detailed information about their ethnic and racial backgrounds. If you decline to state, skip to question .
If you select "yes" in Question 21a, a response to Question 21b is required. Please do not select more than one response in Question 21b as only ONE response is allowed. After completing Question 21b, please answer Questions 21c and 21d. If you have selected "no" or "decline to state", do not answer Question 21b.)
21b. If you indicated (above that you consider yourself Hispanic or Latino, please select the ONE category below that best describes your background:
Argentinean Bolivian Chilean Colombian Costa Rican Cuban
Panamanian Paraguayan Peruvian Puerto Rican Salvadorian Spaniard
Uruguayan Venezuelan Other Central American Other South American Other Hispanic or Latino If Other, specify:
21c. What is your race? (Mark one or as many races below as appropriate for you.) All undergraduate applicants must respond to Question 21c. If you select "decline to state", then you cannot choose any other boxes. The U.S. Census identifies the followin races: White, Black or African American, American Indian or Alaska Native, Asian, and Native Hawaiian or Pacific Islander. These racial categories, as well as many sub-categories, are listed below. You may mark as many races as are appropriate to you. Please mark only one sub-category for each race that you select.
White
Black/African American
American Indian or Alaska Native
Asian
Pacific Islander
European Middle Eastern North Africa Other White Specify:
African American Black Haitian Other African/Black Specify:
Achomawi/Achumawi Cahto Cahuila Chemehuevi Chumash Costanoan/Ohlone Cupeno Gabrielino/Tongva Hupa/Hoopa Kanuk Kumeyaay Luiseno Maidu Miwok Mojave Ohlone Paiute Pomo Quechan Serrano Shoshone Tolwa Wappo Washoe Western Mono Wintun Wiyot Yokuts Yuki Yurok Latin American Indian Other American In. Tribe Specify:
Other Alaska Native Tribe Specify:
Asian Indian Bangladeshi Bhutanese Burmese Cambodian Chinese (except Taiwanese) Filipino Hmong Indo Chinese Indonesian Iwo Jiman Japanese Korean Laotian Malaysian Maldivian Nepalese Okinawan Paskistani Singaporean Sri Lankan Taiwanese Thai Vietnamese Other Asian
Specify:
Carolinian Chuukese Fijian Guamanian or Chomorro I-Kiribati Kosraean SaipaneseMariana Islander Marshallese Natie Hawaiian Ni Vanatu Palauan Papua New Guinean Pohnpeian Saipanese Samoan Solomon Islander Tahitian Tokelauan Tongan Yapese Other Melanesian Other Micronesian Other Polynesian Other Pacific Islander
Specify:
Opt Out:
22. If the CSU is asked to report only ONE summary race/ethnicity description for you please choose the ONE category that you want us to report.
23. Have you ever been on active duty in the U.S. military services? If yes, attach or send a copy of DD214 or DD295 for evaluation of academic credit to the admission office of each campus to which you apply.
24. OPTIONAL: If you have a physical, perceptual, pschological or learning disability, check this box. Special services may be available to accommodate your disability.
25. Certification to be read and signed by all applicants to certify the accuracy of the information provided.
I certify under penalty of perjury that I have provided complete and accurate responses to the items on this application. I further certify all official documents submitted in support of this application are authenticand unaltered records that pertain to me. I authorize release of any information submitted by me in connection with my application to anperson, firm, corporation, association or government agency, but only to verify or explain the information, obtain pertinent records, or in connection with perjury proceedings. My signature certifies the accuracy and compleeteness of the information provided. I understand that any misrepresentation may be cause for denial or cancellation of admission or enrollment.
Applicant's Signature
Date
We encourage you to attend one of our Information Meetings to learn more about these programs. Check the Information Meetings web site for current dates for undergraduate programs.
Please tell us, in brief, about your interests and goals, academic and otherwise:
