APPLICATION FOR ADMISSION

Fields in red are required.

1. Social Security Number:

2. Full Legal Name:

Last:

First:

M.I.:

3. Other name used on educational records:
(if different from above, such as maiden name)

4. Telephone Numbers:

Home

Work

5. Mailing Address:
Street and Number
City		State		Zip Code

6.  Physical Address:
Street and Number
City		State		Zip Code

7.  How long have you lived at the above physical address:

Years:

Months:

San Miguel Mora Guadalupe Colfax Other

Enter County:
Enter State:

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The following voluntary information is needed to aid in establishing and maintaining educational programs with equal opportunity for all groups.  All information will be kept confidential and will not be used for admission purposes.

9.  Gender:

Female Male

10. Date of Birth:   Month:     Day:      Year:

11.  Marital Status:

Married Single Separated Widow

12. Ethnic origin

White, Non-Hispanic Black, Non-Hispanic Hispanic Non-Resident Alien American Indian/Alaskan Native Asian American/Pacific Islander Unknown/No Response

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13. Are you a U.S. citizen?

Yes No

Indicate country:
Are you an immigrant or permanent resident?	Yes No

Visa Type: (Must Provide Documentation)

Alien Registration No.

Expiration Date

14. Semester you plan to enroll:

Fall Spring Summer

Year

15. What is your educational goal at LCC?  

Associate Degree Certificate Community and Continuing Education Professional or Personal Enrichment Transfer courses to another college Undeclared (Pre-Nursing)

Program of Study:

None test

16. Have you previously attended LCC?

Yes No

When?

17. Which site do you plan on attending?

LCC Main Springer Santa Rosa Off Site

(identify location)

18. High school last attended:

Name of High School:
City:		State:

19. High School Diploma or GED?

High School Diploma GED Home School Diploma None

NM Out of State

Graduation or Completion: Month     Year

20. List all technical schools, colleges and universities you attended after high school graduation or after you obtained your GED.  Include enrollment at LCC.

Full Name of School	City	State	From (month/year)	To (month/year)	Certificate/Degree

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If you graduated from an Out-of-State high school OR did not graduate from West Las Vegas Schools, Las Vegas City Schools, Santa Rosa Consolidated Schools, Mora Independent Schools, Springer Municipal Schools, Maxwell Municipal Schools or Wagon Mound Public Schools, you must complete questions 21-31 to be considered for in-state/in-district tuition classification. Failure to do so will result in an automatic non-resident/out-of-district tuition classification.

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Did you graduate from one of the following schools?

West Las Vegas Schools	Las Vegas City Schools	Santa Rosa Consolidated Schools
Mora Independent Schools	Springer Municipal Schools	Maxwell Municipal Schools
Wagon Mound Public Schools

Yes No

21. What state do you regard as your permanent home?

22. How long have you lived in LCC's participating school district?

Years:

Months:

**The paricipating school districts are: West Las Vegas Schools, Las Vegas City Schools, Santa Rosa Consolidated Schools, Mora Independant Schools, Springer Municipal Schools, Maxwell Municipal Schools and Wagon Mound Public Schools.

23. Have you lived in New Mexico for the past 12 consecutive months?

Yes No

24. Are you a registered voter?

Yes No

In which county?

San Miguel Guadalupe Mora Colfax Other

County:   State:

25. Do you have a current drivers license?

Yes No

State:

Date Issued:

26. Do you have a current state issued ID card?

Yes No

State that issued ID:

27. Do you have a vehicle registered in your name?

Yes No

State:

Date:

28. Did you file a New Mexico personal income tax report in the immediate past year?

Yes No

29. If younger than 23 years of age, did your parent(s) or legal guardian claim you as a dependant on their federal tax return in the immediate past year?
Yes No

Have your parents/guardians lived in New Mexico for the past 12 consecutive months?	Yes No
(A duplicate copy of pages one and four of the 1040, 1040A or 1040EZ and additional documentation may be required.)

30. Do you intend to maintain permanent New Mexico residence, thereby relinquishing residence in all other states?

Yes No

31. List names of employers, locations and dates of employment during the past two years:

Employer	City and State	Dates of Employment