NAME__________________________________________ID #______-____-______ DATE______________

ADDRESS________________________________________________________COUNTY________________

CITY____________________________________STATE____________ZIP CODE_________________

TELEPHONE NUMBER(H)_______________________________(W)________________________________

E-MAIL ADDRESS______________________________________

HIGH SCHOOL (OR COLLEGE) QPI_____________________________SAT (Combined)_______________

ACT (Combined)____________________________________________________________________________

HIGH SCHOOL/COLLEGE MOST RECENTLY ATTENDED
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HIGH SCHOOL/COLLEGE ADVISOR_____________________________TELEPHONE #_____________

STUDENT STATUS AT GENESEE COMMUNITY COLLEGE (NEW)__________(CONTINUING)_______

TWO REFERENCES (LIST NAME, TITLE, ADDRESS,AND TELEPHONE NUMBER)

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WRITTEN STATEMENT: (PLEASE ATTACH YOUR WRITTEN STATEMENT TO THIS APPLICATION
FORM).
Rev 11/28/01 **