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2011-12 First-year Application For Spring 2012 or Fall 2012 Enrollment APPLIC ANT Legal Name ___________________________________________________________________________________________________________________ Last/Family/Sur (Enter name exactly as it appears on official documents.) First/Given Middle (complete) Jr., etc. Preferred name, if not first name (only one) ____________________________ Former last name(s) _____________________________________________ Birth Date ____________________
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  2011-12 First-year Application For Spring 2012 or Fall 2012 Enrollment  AP-1  /  2011-12 © 2011 The Common Application, Inc.  APPLICANT Legal Name ___________________________________________________________________________________________________________________ Last/Family/Sur (Enter name  exactly  as it appears on official documents.)First/Given Middle (complete)Jr., etc. Preferred name, if not first name (only one)____________________________Former last name(s) _____________________________________________Birth Date____________________________________________________US Social Security Number, if any ___________________________________ mm/dd/yyyy Required for US Citizens and Permanent Residents applying for financial aid via FAFSA  Preferred Telephone  Home  Cell Home (_______) __________________________________ Cell (_______) __________________________________  Area/Country/City CodeArea/Country/City Code  E-mail Address ________________________________________________IM Address ____________________________________________________Permanent home address __________________________________________________________________________________________________________ Number & StreetApartment #  ____________________________________________________________________________________________________________________________ City/TownCounty or ParishState/ProvinceCountryZIP/Postal Code  If different from above , please give your current mailing address for all admission correspondence. (from ___________ to ___________) (mm/dd/yyyy)(mm/dd/yyyy)  Current mailing address __________________________________________________________________________________________________________ Number & StreetApartment #  ____________________________________________________________________________________________________________________________ City/TownCounty or ParishState/ProvinceCountryZIP/Postal Code  If your current mailing address is a boarding school, include name of school here: _________________________________________________________________ FUTURE PLANS  Your answers to these questions will vary for different colleges. If the online system did not ask you to answer some of the questions you see in this section, this collegechose not to ask that question of its applicants.College ________________________________________________________Deadline ______________________________________________________ mm/dd/yyyy  Entry Term:  Fall (Jul-Dec)  Spring (Jan-Jun)Decision Plan___________________________________________________  Academic Interests_____________________________________________________________________________________________________________________________________________________________________Career Interest_________________________________________________Do you intend to apply for need-based financial aid?  Yes  NoDo you intend to apply for merit-based scholarships?  Yes  NoDo you intend to be a full-time student?  Yes  NoDo you intend to enroll in a degree program your first year?  Yes  NoDo you intend to live in college housing?______________________________What is the highest degree you intend to earn?_________________________ DEMOGRAPHICS    Female  MaleCitizenship Status______________________________________________Non-US Citizenship________________________________________________________________________________________________________________________________________________________________________Birthplace________________________________________________________ City/Town State/Province Country   Years lived in the US? ____________ Years lived outside the US? ____________Language Proficiency (Check all that apply.) S(Speak) R(Read) W(Write) F(First Language) H(Spoken at Home)  SRWFH_______________________________________________  _______________________________________________  _______________________________________________  Optional The items with a gray background are optional. No information youprovide will be used in a discriminatory manner. Religious Preference _______________________________________________US Armed Services veteran status_____________________________________1. Are you Hispanic/Latino?   Yes, Hispanic or Latino (including Spain)  No If yes, please describe your background. ____________________________________________________________2. Regardless of your answer to the prior question, please indicate how you identifyyourself. (Check one or more and describe your background.)   American Indian or Alaska Native (including all Original Peoples of the Americas)  Are you Enrolled?  Yes  No If yes, please enter Tribal Enrollment Number________________ ____________________________________________________________   Asian (including Indian subcontinent and Philippines)____________________________________________________________  Black or African American (including Africa and Caribbean)____________________________________________________________  Native Hawaiian or Other Pacific Islander (Original Peoples)____________________________________________________________  White (including Middle Eastern)___________________________________________________________   AP-2  /  2011-12 © 2011 The Common Application, Inc. FAmILY  Please list both parents below, even if one or more is deceased or no longer has legal responsibilities toward you. Many colleges collect this information for demographicpurposes even if you are an adult or an emancipated minor. If you are a minor with a legal guardian (an individual or government entity), then please list that informationbelow as well. If you wish, you may list step-parents and/or other adults with whom you reside, or who otherwise care for you, in the  Additional Information section . Household Parents’ marital status (relative to each other): p Never Married p Married p Civil Union/Domestic Partners p Widowed p Separated p Divorced (date _________) mm/yyyy  With whom do you make your permanent home?   p Parent 1 p Parent 2 p Both p Legal Guardian p Ward of the Court/State p OtherIf you have children, how many? _________ Legal Guardian   (if other than a parent)  Relationship to you ___________________________________________________________________________________________________________ Last/Family/Sur First/Given Middle Title (Mr./Mrs./Ms./Dr.)  Country of birth ________________________________________________Home address if different from yours________________________________________________________________________________________________________________________Preferred Telephone: p Home p Cell p Work (_______) ________________ Area/Country/City Code  E-mail _______________________________________________________Occupation _____________________________________________________Employer _____________________________________________________College (if any) ___________________________________ CEEB________Degree _________________________________________ Year _________Graduate School (if any) ____________________________ CEEB________Degree _________________________________________ Year _________ Siblings Please give names and ages of your brothers or sisters. If they are enrolled ingrades K-12 (or international equivalent), list their grade levels. If they haveattended or are currently attending college, give the names of the undergraduateinstitution, degree earned, and approximate dates of attendance. If more thanthree siblings, please list them in the Additional Information section. ____________________________________________________________ Name Age & Grade Relationship  College Attended ___________________________________ CEEB _______Degree earned _________________________ Dates __________________or expected mm/yyyy – mm/yyyy  ____________________________________________________________ Name Age & Grade Relationship  College Attended ___________________________________ CEEB _______Degree earned _________________________ Dates __________________or expected mm/yyyy – mm/yyyy  ____________________________________________________________ Name Age & Grade Relationship  College Attended ___________________________________ CEEB _______Degree earned _________________________ Dates __________________or expected mm/yyyy – mm/yyyy  Parent 1 :   p Mother p Father p UnknownIs Parent 1 living? p Yes p No (Date Deceased ____________________) mm/yyyy  ____________________________________________________________ Last/Family/Sur First/Given Middle Title (Mr./Mrs./Ms./Dr.)  Country of birth ________________________________________________Home address if different from yours________________________________________________________________________________________________________________________Preferred Telephone: p Home p Cell p Work (_______) ________________ Area/Country/City Code  E-mail _______________________________________________________Occupation _____________________________________________________Employer _____________________________________________________College (if any) ___________________________________ CEEB________Degree _________________________________________ Year _________Graduate School (if any) ____________________________ CEEB________Degree _________________________________________ Year _________ Parent 2 :   p Mother p Father p UnknownIs Parent 2 living? p Yes p No (Date Deceased ____________________) mm/yyyy  ____________________________________________________________ Last/Family/Sur First/Given Middle Title (Mr./Mrs./Ms./Dr.)  Country of birth ________________________________________________Home address if different from yours________________________________________________________________________________________________________________________Preferred Telephone: p Home p Cell p Work (_______) ________________ Area/Country/City Code  E-mail _______________________________________________________Occupation _____________________________________________________Employer _____________________________________________________College (if any) ___________________________________ CEEB________Degree _________________________________________ Year _________Graduate School (if any) ____________________________ CEEB________Degree _________________________________________ Year _________ - - -   AP-3  /  2011-12 © 2011 The Common Application, Inc. EDUCATION Secondary Schools Most recent secondary school attended______________________________________________________________________________________________Entry Date _________________ Graduation Date _________________ School Type:  Public  Charter  Independent  Religious  Home School mm/yyyymm/dd/yyyy   Address ________________________________________________________________________________ CEEB/ACT Code ___________________________ Number & Street  __________________________________________________________________________________________________________________________________ City/TownState/ProvinceCountryZIP/Postal Code  Counselor’s Name __________________________________________________________Counselor’s Title _______________________________________E-mail _____________________________________ Telephone (_______) ______________________ Fax (_______) ________________________________  Area/Country/City Code Number Ext.Area/Country/City Code Number  List all other secondary schools you have attended since 9 th grade, including summer schools or enrichment programs hosted on a secondary school campus: School Name & CEEB/ACT Code Location (City, State/Province, ZIP/Postal Code, Country) Dates Attended (mm/yyyy) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Community Program/Organization._______________________________________________________________________________________________________If your education was or will be interrupted, please indicate so here:_____________________________________________________________________________ Colleges & Universities Report all college attendance (including online) since 9 th grade and indicate as College Course (CO) or Enrichment Program (EP) hosted on acollege campus. College/University Name & CEEB/ACT CodeLocation (City, State/Province, ZIP/Postal Code, Country)Degree Candidate?CO EPDates AttendedDegree EarnedYes No mm/yyyy – mm/yyyy _________________________________ ___________________________________________    ______________ __________________________________________ ___________________________________________    ______________ __________________________________________ ___________________________________________    ______________ _________ Were you issued a transcript for any work listed above?  Yes  No If yes, please have an official transcript sent as soon as possible.  ACADEMICS The self-reported information in this section is not intended to take the place of your official records. Please note the requirements of each institution to which you areapplying and arrange for official transcripts and score reports to be sent from your secondary school and the appropriate testing agencies. Where “Best Scores” arerequested, please report the highest individual scores you have earned so far, even if those scores are from different test dates. Grades Class Rank_________ Class Size _________ Weighted?  Yes  NoGPA _________ Scale _________ Weighted?  Yes  No (if available)(if available)  ACT Exam Dates: ________ ________ ________Best Scores: _________ _______________ _______________ ______ (past & future)mm/yyyymm/yyyymm/yyyy(so far)COMPmm/yyyyEnglishmm/yyyyMathmm/yyyy  _________ _______________ _______________ ______ Readingmm/yyyySciencemm/yyyyWritingmm/yyyy  SAT Exam Dates: ________ ________ ________Best Scores: _________ _______________ _______________ ______ (past & future)mm/yyyymm/yyyymm/yyyy(so far)Critical Readingmm/yyyyMathmm/yyyyWritingmm/yyyy  TOEFL/ Exam Dates: ________ ________ ________Best Score: _________ ______ ______ IELTS (past & future)mm/yyyymm/yyyymm/yyyy(so far)TestScoremm/yyyy  AP/IB/SATSubjects Best Scores: ________ __________________________________ _____ ________ __________________________________ _____ (per subject, so far)mm/yyyyType & SubjectScoremm/yyyyType & SubjectScore  ________ __________________________________ _____ ________ __________________________________ _____ mm/yyyyType & SubjectScoremm/yyyyType & SubjectScore  ________ __________________________________ _____ ________ __________________________________ _____ mm/yyyyType & SubjectScoremm/yyyyType & SubjectScore  ________ __________________________________ _____ ________ __________________________________ _____ mm/yyyyType & SubjectScoremm/yyyyType & SubjectScore  Current Courses Please indicate title, level (AP, IB, advanced honors, etc.) and credit value of all courses you are taking this year. Indicate quarter classes taken inthe same semester on the appropriate semester line. Full Year/First Semester/First Trimester Second Semester/Trimester Third Trimester or additional first/second term courses if more space is needed  ________________________________________ ________________________________________ _________________________________________________________________________________ ________________________________________ _________________________________________________________________________________ ________________________________________ _________________________________________________________________________________ ________________________________________ _________________________________________________________________________________ ________________________________________ _________________________________________________________________________________ ________________________________________ _________________________________________________________________________________ ________________________________________ _________________________________________________________________________________ ________________________________________ _________________________________________   AP-4  /  2011-12 © 2011 The Common Application, Inc. Honors Briefly list any academic distinctions or honors you have received since the 9 th grade or international equivalent (e.g., National Merit, Cum Laude Society). S(School) S/R(State or Regional N(National) I(International)  Grade level orpost-graduate (PG)Honor Highest Level ofRecognition9 10 11 12 PG SS/RNI  _________________________________________________________________________________________________  _________________________________________________________________________________________________  _________________________________________________________________________________________________  _________________________________________________________________________________________________  _________________________________________________________________________________________________  EXTRACURRICULAR ACTIVITIES & WORK EXPERIENCE Extracurricular Please list your principal extracurricular, volunteer, and work activities in their order of importance to you . Feel free to group your activities andpaid work experience separately if you prefer. Use the space available to provide details of your activities and accomplishments (specific events, varsity letter, musicalinstrument, employer, etc.). To allow us to focus on the highlights of your activities, please complete this section even if you plan to attach a résumé . Grade level orpost-graduate (PG)Approximatetime spent When did you participatein the activity? Positions held, honors won, letters earned, or employerIf applicable,do you planto participatein college?9 10 11 12 PG Hoursper week Weeksper yearSchoolyearSummer/SchoolBreak   _______________________________________________________________________   Activity _________________________________________________________________________________________________________________  _______________________________________________________________________   Activity _________________________________________________________________________________________________________________  _______________________________________________________________________   Activity _________________________________________________________________________________________________________________  _______________________________________________________________________   Activity _________________________________________________________________________________________________________________  _______________________________________________________________________   Activity _________________________________________________________________________________________________________________  _______________________________________________________________________   Activity _________________________________________________________________________________________________________________  _______________________________________________________________________   Activity _________________________________________________________________________________________________________________  _______________________________________________________________________   Activity _________________________________________________________________________________________________________________  _______________________________________________________________________   Activity _________________________________________________________________________________________________________________  _______________________________________________________________________   Activity _________________________________________________________________________________________________________________
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