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Application for Admission
CURRENT NAME (Required fields are in red)
Last Name:     Full First Name:    Middle Initial:
FORMER NAME(s)
Last Name: Full First Name: Middle Initial:
Address: City: State: Zip:
County:    Phone:
Email Address:     *Social Security Number:  
*GENDER: Male   Female       *Date of Birth:

*RACE:  This section is voluntary.  Demographic information is reported to the U.S.Office for Civil Rights under Title VI of the Civil Rights Act of 1964 and Title IX of the Education Ammendments of 1972.  It is not used in decisions, and will not be used in a discriminatory way for participation in, access to, or benefits of programs or services of the college.     Are you Multiracial (09)  Yes  No

Select one or more as appropriate:
White (01) Black or African American (02) Asian (03)
American Indian or Alaska Native (04) Hispanic (05)
Native Hawaiian or other Pacific Islander (08) Other/Unknown (07)
*CITIZENSHIP STATUS:
U.S. Citizen
Non-resident Alien (06) - Country of Citizenship:
Permanent Resident - Alien Registration #:
*Indicates optional information, failure to provide this information will NOT affect your acceptance at Glen Oaks.
Educational Background
Last high school attended:
                               City: State: Zip:
I graduated or will graduate on: (month/year)
GED (month/year)       Non-graduate
                                                              *Highest grade completed.
College(s) attended (List most recent first):
Name of College(s):  
College - City / State:
Name of College(s):  
College - City / State:
Name of College(s):  
College - City / State:
*Do either of your parents have a four-year college degree (bachelors)?
         Yes    No
*Indicates optional information, failure to provide this information will NOT affect your acceptance at Glen Oaks.
Educational Intent
I plan to start classes in 20
FALL (Aug./Sept.)        WINTER (Jan.)         SPRING/SUMMER (May/June)
Student Status (check one)
    First-time in any college
    Former GOCC student: Year last attended
    Transfer (Previous enrollment at another college)
    Guest student from another college
    Taking classes while in high school      (NOTE: Must submit Early College Admissions Application)
I plan to (check one)
    Earn an Occupational Certificate or Associate Degree
    Transfer to a college or university
    Gain the skills necessary to enter a new occupation, or retrain or advance in my present position
    Satisfy a personal interest
    My educational plans are uncertain at this time
Please check a box for the anticipated program of study:

Accounting (103)
Automotive Service (106)
Automotive Technician (109)
Computer Information Sys. (155)
Computer Support Technician (159)
Database/Programming (156)
Drafting & Design (127)
Early Childhood Education (128)
Machine Tool Tech. (139)

Management/Marketing (145)
Management/Supervision (149)
Medical Administrative Specialist (181)
*Medical Assistant (169)
Office Administrative Asst., Executive (161)
Office Administrative Asst., Legal (162)
*Practical Nursing, LPN (004)
Truck Driver (110)
Web Design (157)
NOTE: If selecting an Occupational Degree you must also select a Certificate program.
*Must apply to the Assistant Dean of Nursing & Allied Health for selective admissions.
Please check a box for Transfer Degree Programs:
Associate of Arts (201)
Associate of Business (220)
Associate of General Studies (206)		 Associate of Science (210)
Assoc. of Early Childhood Education (203)
Please check a box for Occupational Degree Programs:
Assoc. of Applied Science in Allied Health (270)
Assoc. of Applied Science in Business (250)

*Assoc. of Applied Science in Nursing (005)
 Associate of Science in Technology (230)
NOTE: If selecting an Occupational Degree you must also select a Certificate program.
*Must apply to the Assistant Dean of Nursing & Allied Health for selective admissions.
Please check a box for Other Programs:
Undecided, Seeking Degree/Cert.(002)
Transfer; Not completing a degree/cert. (006)		 Personal Interest(001)
       (Lifelong Learning/Job Skills)
Joint Transfer Program w/Another College (011)
      Refer to GOCC Catalog to indicate program name.
If program of interest is not listed, please enter the program name here:
Interests and Activities
Art Athletics   (name of sport): Choir

 Science   

If you have questions, call the GOCC Admissions Office,
toll free 1-888-994-7818 or 467-9945.

How did you hear about Glen Oaks? *  (Select the one that most influenced your decision to apply)

  Alumni              Common Knowledge                  Mailings           Referral           Friend

  College Night     Radio           Web Site         Newspaper      Bulletin Board/Billboard

  Career Fair        High School Counselor/Teacher                               Employer        

  Other                                                                          * This section is optional

Glen Oaks Community College is committed to a policy of providing equal access to education for all persons regardless of race, color, sex, age, religion, national origin, sexual orientation ,disability, veteran status, or other status as protected by law.  The College's nondiscrimination policy applies to admissions, employment, and access to college programs and activities.  This policy applies to all persons employed at GOCC, enrolled as a student, seeking admission to the college, requesting employment at, or having contracts with the college.  The College values diversity and seeks talented students, faculty and staff from diverse backgrounds.  The College does not discriminate in the administration of educational policies, programs or activities: admission policies: scholarship and loan awards: or other college administered programs or employment.  The College's Civil Rights Coordinator has copies of all Acts and regulations and can provide information on grievance procedure and will investigate all complaints.  Inquiries concerning the non-discriminatory policy may be directed to Director, Office of Civil Rights, U.S. Dept. of Education, 400 Maryland Ave. S.W., Washington, D.C. 20202  Phone (216) 522-4970
Submission of this form by "s/Name" electronically, shall constitute my signature on the form. By submitting this form, I certify that the information given on this application is correct and complete to the best of my knowledge, and I agree to observe all the rules and regulations of Glen Oaks Community College.  I understand that false information on this application may result in my dismall from Glen Oaks Community College.