Employee Fee Waiver Program Graduate Application for Admission For Office Use Only Applicant Plans to Enroll in Approved California State University, Chico Fee Status: _____ By _____ Career Advancement or Res. Status: _____ By _____ Job-Related Courses A $55 non-refundable check or money order or completed CSU Request to Waive Admission Application Fee form MUST accompany this application. Semester/Year Have you applied to this campus before? Did you enroll? Fall: Yes Term: Yes SSN: Spring: No Year: No Chico State ID #: Legal name as you wish Last Name First Name Middle Name it to appear on your permanent record Other names(s) that may appear on your record Physical Address County (or Country if not USA) Mailing Address County (or Country if not USA) Permanent Address if different from above: Home Phone: Birth Date: Sex: Male Female Month / Day / Year Business Phone: Birthplace: Email Address: Degree Objective: MA MS Major & Option or Emphasis: Credential: Objective: Other: Citizenship Status: U.S. Citizen Non-U.S. Citizen, F Visa Non-U.S. Citizen, J Visa Immigrant, (I-551 Needed) Refugee Other: Country of Citizenship: USA Other Country: Alien Registration No. Date Issued: Do you need special services to accommodate a physical, perceptual or learning disability? Yes No Have you ever been convicted of a felony? Yes No List all institutions & locations attended since high school (even if Enrolled Fee Status no work was completed), and those you are now attending or plan Units Degree Date Degree Resident or to attend before enrolling at CSU, Chico. Attach an extra sheet, if From To Completed Earned (to be) Earned necessary. (Include CSU, Chico, if applicable.) Non-resident City/State Mo Yr Mo Yr Sem Qtr Cumulative GPA for all List Admissions tests (GRE, GMAT, MAT, TOEFL, Are you under academic or disciplinary suspension, disqualification, previous College Work: IELTS) taken or planned and give test date(s): expulsion or similar action? Yes No If yes, indicate type of action: Residency Status: Your responses to the following questions are required to make a preliminary assessment of your residency status for admission and tuition purposes. The campus may request additional information prior to making a final residency determination. List places you lived BEFORE your present stay in California began, & the parent/guardian with whom you resided. From date To Date State or Country Parent/Legal Guardian What state do you regard as your permanent home? Do you claim California Residency? Yes No If you claim California residency, when did your present stay begin? Have you lived in California continuously since birth? Yes No Are you claimed as a dependent on the military record of any member of the U.S. armed forces?: Yes No Are you a Veteran of the military? Yes No Do you possess a driver's license or State ID card? Yes No If yes, give state, date of issuance & license number: St. Date Lic. No. PDEV-FWJobRelatedGraduateApp.pdf Page 1 of 4 Last Update: 12/2011 To conform with the new guidelines of the U.S. Federal Office of Management and Budget (http://www.whitehouse.gov/omb), the California State University must collect from applicants detailed information about their ethnic and racial backgrounds. If you select "Yes" in Question 20a, a response to Question 20b is required. Please do not select more than one response in Question 20b as only ONE response is allowed. If you have selected "No" or "Decline to State," do not answer Question 20b. Ethnicity 20a. In regard to your ethnicity, do you consider yourself Hispanic or Latino? Yes No Decline to State (If "No" or "Decline to State", please go to Question 21.) 20b. If you indicated Yes on Question 20a (above), please select the ONE category below that best describes your background. (Do not select more than one.) Argentinean Panamanian Bolivian Paraguayan Chilean Peruvian Colombian Puerto Rican Costa Rican Salvadorian Cuban Spaniard Dominican (Republic) Uruguayan Ecuadorian Venezuelan Guatemalan Other Central American Honduran Other South American Mexican Other Hispanic or Latino Please specify Nicaraguan 21. Race (All undergraduate applicants must respond to Question 21.) The U.S. Census identifies the following 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. Mark one or as many races below as appropriate for you. You may mark as many race categories as are appropriate to you. Please mark only one sub-category for each race category that you select. If you select "Decline to State," then you cannot choose any other boxes. Decline to state White Black or African American (Please select ONE sub-category that best describes (Please select ONE sub-category that best describes your background.) your background.) European African American Middle Easterner Black North African Haitian Other White Other African/Black Please specify Please specify Asian (Please select ONE sub-category that best describes your background.) Asian Indian Indo Chinese Nepalese Bangladeshi Indonesian Okinawan Bhutanese Iwo Jiman Pakistani Burmese Japanese Singaporean Cambodian Korean Sri Lankan Chinese (except Taiwanese) Laotian Taiwanese Filipino Malaysian Thai Hmong Maldivian Vietnamese Other Asian Please specify PDEV-FWJobRelatedGraduateApp.pdf Page 2 of 4 Last Update: 12/2011 American Indian or Alaska Native (Please select ONE sub-category that best describes your background.) Achomawi/Achumawi Cahto (e.g., Cahto Indian Tribe of the Laytonville) Cahuilla (e.g., Agua Caliente Band of Cahuilla Indians) Chemehuevi (e.g., Chemehuevi Indian Tribe of the Chemehuevi Reservation, California) Chumash (e.g., Santa Ynez Band of Chumash Mission) Costanoan/Ohlone Cupeno (e.g., Los Coyotes Band of Cahuilla & Cupeno) Gabrielino/Tongva Hupa/Hoopa (e.g., Hoopa Valley Tribe, California) Karuk (e.g., Karuk Tribe of California) Kumeyaay (e.g., Ewiiaapaayp Band of Kumeyaay) Luiseno (e.g., La Jolla Band of Luiseno Mission) Maidu (e.g., Enterprise Rancheria of Maidu Indians) Miwok (e.g., Ione Band of Miwok Indians) Mojave (e.g., Fort Mojave Indian Tribe of Arizona) Ohlone Paiute (e.g., Fort Independence Indian Community of Paiute Indians of the Fort) Pomo (e.g., Coyote Valley Band of Pomo Indians) Quechan (e.g., Quechan Tribe of the Fort Yuma Indians) Serrano (e.g., San Manuel Band of Serrano Mission) Shoshone (e.g., Paiute-Shoshone Indians of the Bishop Community of the Bishop Colony) Tolowa Wappo Washoe Western Mono (e.g., Big Sandy Rancheria of Mono Indians) Wintun (e.g., Cachil DeHe Band of Wintun Indians of the Colusa Indian Community) Wiyot (e.g., Wiyot Tribe, California/formerly the Table Bluff Reservation - Wiyot Tribe) Yokuts Yuki Yurok (e.g., Yurok Tribe of the Yurok Reservation) Latin American Indian Other American Indian Tribes Please specify Other Alaska Native Tribes Please specify PDEV-FWJobRelatedGraduateApp.pdf Page 3 of 4 Last Update: 12/2011 Native Hawaiian or Other Pacific Islander (Please select ONE sub-category that best describes your background.) Carolinian Saipanese Chuukese Samoan Fijian Solomon Islander Guamanian or Chomorro Tahitian I-Kiribati Tokelauan Kosraean Tongan Mariana Islander Yapese Marshallese Other Melanesian Native Hawaiian Other Micronesian Ni-Vanuatu Other Polynesian Palauan Other Pacific Islander Please specify Papua New Guinean Pohnpeian 22. If the California State University is asked to report only ONE summary race/ethnicity description for you, please choose the ONE category below that you want us to report. (All undergraduate applicants must respond to Question 22. Please check only ONE box.) American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Asian White Black or African American Two or more races/ethnicities Hispanic or Latino Decline to State I certify that the above and any other information submitted by me in conjunction with my application is accurate and complete. Signed At: City and County Signature Date PDEV-FWJobRelatedGraduateApp.pdf Page 4 of 4 Last Update: 12/2011.