SONOMA STATE UNIVERSITY EXTENDED EDUCATION
Liberal Studies BA Degree Completion Program

Application for Admission

Office Use Only:

Record
Date
Employee ID
Application #
Fee
By

Please fill out and print, then follow instructions at bottom of form.
1.I am applying for Fall semester ( indicate year)

2. Social Security#

3. If you have previously applied to or attended this campus, please list

Date of Application (term) (year)

Last term attended(term) (year)

Previous student file # (if different than SSN)

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 Sonoma State University 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.

4. Legal name last first initial

5. Other names that may appear on your academic records:

last first initial

6a. Current Mailing Address

City State Zip

6b. Permanent Address (if different than current)

City State Zip

7a. Home Phone 7b. Cell phone

7c. Daytime phone

email address

8. Birth Date (month/day/year) 9. Sex (enter M or F)

10. Name of intended major Major code

11. How many total transferable semester units will you have completed at time of entry/reentry in CSU?
(include units in progress and planned; semester units=quarter units x 2/3)

12. What is your degree objective?

13. GPA for all transferable undergraduate college work (estimate): GPA
14. Are you eligible to reenroll at all institutions previously attended? Yes No
If not, attach an explanation and name any institution you are ineligible to reenter.

15. List the names and locations of all colleges and universities attended, even if no coursework was completed. Begin with the last institution attended. Attach a separate sheet if you need more space. For units in progress and planned, see item 16.

ALL INSTITUTIONS
School name and location


PERIOD ENROLLED

From (mo/yr) - To (mo/yr)

TRANSFERABLE
Units Completed

Semester/Quarter
DEGREE
RECEIVED
List degree and date received (or to be)
-
-
-
-
-
-

Please send two official copies of transcripts from all colleges/universities to: SSU Extended Education,
ATTN: Beth Warner
Hutchins School of Liberal Studies
1801 E Cotati Ave.
Rohnert Park, CA 94928-3609
We cannot process your application until all transcripts have been received.

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 # and Title
Units

Courses Planned

Institution
Term/Year
Dept. Course # and Title
Units

17. Please list courses completed or in progress that meet the CSU General Education requirements in A1 Oral Communication, A2 Written Communica5ion, A3 Critical Thinking, and B4 Mathematics/Quantitative Reasoning.

INSTITUTION
TERM/YEAR
DEPT. COURSE # / TITLE
UNITS
GRADE
(if in progress or planned, use IP)
Oral Communication
Written Communication
Critical Thinking
Quantitative Reasoning

18a High School Diploma? (check if "yes") GED (check if "yes")

18b State issued by

18c Month and Year received

19. Permanent residence
If you live in California, list county of residence

If you live outside of California, list other U.S. state or country

20. Country of citizenship (all must answer).

20b. If you were born outside the U.S, what year did you move to the U.S?

Enter your citizenship code in box
Y - U.S. citizen R - Refugee F - F visa J - J visa I - Immigrant I-551 (green card) Date issued:
O - Other visa (specify) Date issued: N - None of the above

21a. Is English your first language?

21b. If your first language is not English, please list it:

22. Select your ethnic code from menu below (optional):

23. If you have been on active duty in the U.S. military services, enter a Y in box
Attach a copy of DD214 or DD295 for evaluation of credit.

24. If you have a physical, perceptual, psychological or learning disability,
enter a Y in the box. (optional) Special services may be available to accommodate your disability.

24. Certification: I certify under penalty of perjury, or after first being duly sworn, that I have provided complete and accurate responses to the items on this application. I further certify (swear) all official documents submitted in support of this application are authentic and unaltered records that pertain to me. I authorize release of any information submitted by me in connection with my application to any person, 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 completeness of the information provided.

I understand that any misrepresentation may be cause for denial or cancellation of admission or enrollment.

Applicant's signature

Date

Mail completed application along with a check for $55 payable to Sonoma State University to:

Beth Warner
Hutchins School of Liberal Studies
1801 E. Cotati Ave.
Rohnert Park, CA 94928-3609