Name:
Last/Family:  First/Given:  Middle:

Home Country Address: (as it would read on an envelope)

Current Mailing Address: (as it would read on an envelope)

Agent Mailing Address: (as it would read on an envelope)

Which address do you want us to use in sending correspondence?
Home   Current  Agent   Other:

Home Telephone Number: (include area or country code)

Current Telephone Number: (include area or country code)

Fax  Number: (include area or country code)

E-mail:

Gender: Male   Female

Date of Birth (mo/day/year):

Marital Status: Married   Single

Country of Birth:

Country of Citizenship:

Native language:

TOEFL: Date  Score

I am interested in English as a Second Language Yes     No

I plan to enroll: (Please mark the correct boxes)
4 year (LCSC Bachelor's Degree)   2 year (LCSC Associate's Degree)  
1 year (LCSC Certificate)  Non degree (LCSC)  English as a Second Language (IIE)

Intended Start Date-LCSC: Fall (August)   Spring (January)   Summer (June)   
Year:

Intended Major Field of Study:
4-Year Program:   ******************************************************** Undeclared ************************************************** BACHELOR DEGREES: Business Administration Business Admin: Accounting Emphasis Hotel/Restaurant Management Management Interdisciplinary: Business Education, Elementary Education Kinesiology/Health: Sec Education Kinesiology: Excerise Sci/Sports Med/Corp Fit Kinesiology: Health Promo/Personal Training Kinesiology: Sports Administration/Coaching Kinesiology: Youth Sports/Recreation Psychology Communication Arts Interdisciplinary: Communications English English, Secondary Education English, Creative Writing Interdisciplinary Studies: English Biology Chemistry Chemistry: Geology Emphasis Computer Science Computer Science: Info Sys Emphasis Computer Science: Web-Based Emphasis Earth Information Systems Interdisciplinary Studies: Nat Science Mathematics Mathmatics-Secondary Education Natural Science: Composite Natural Science: Secondary Education Nursing BSN Nursing BSN (already have an RN) Interdisciplinary Studies: Soc Science Justice Studies: Criminal Justice Justice Studies: Human Services Social Science Social Science-Secondary Education Social Work (BSW) ******************************************************* PRE-PROFESSIONAL PROGRAMS: Pre-Dentistry Pre-Engineering Pre-Law Pre-Medicine Pre-Optometry Pre-Pharmacy Pre-Physical Therapy Pre-Veterinary Medicine

2- and 1-Year Program:   ****************************************************** ASSOCIATES DEGREES: Administrative Assistant Bookkeeping Business Management Early Childhood Development Graphics Arts/Printing Technology Hotel/Restaurant Management Legal Assistant Medical Assistant Medical Office Paralegal Web Development Paraprofessional Education Liberal Arts Liberal Arts: Humanities Liberal Arts: Natural Science Liberal Arts: Social Science Practical Nursing Radiographic Science Engineering, AS Behavioral Science Auto Mechanics Technology Automated Manufactoring Technology Collision Repair Diesel Technolgoy Electronics Technician Engineering Technology: Civil Engineering Technology: GIS Engineering Technology: Mechanical Path Engineering Technology: Traditional Heating, Air Conditional & Appliance Industrial Electronics Technology Information Systems Analysis Welding Technology *************************************** CERTIFICATES: Elementary Education Certificate, PB Secondary Education Certficate, PB Special Education Certficate, PB Digital Imaging, Certif. Early Childhood Development, Certif. Food and Beverage Mgmt, Certif. Legal Office Technology, Certif. Medical Biller/Coder, Certif. Medical Receptionist, Certif. Medical Transcription, Certif. Office Technology, Certif. Offset Press, Certif. Paralegal, Certif. Retailing, Certif. Rooms Division Mgmt, Certif. Supervision, Certif. Web Authoring, Certif. Auto Mechanics Technology, Certif. Automated Manufacturing Tech, Certif. Collision Repair, Certif. Diesel Technology, Certif. Engineering Technology, Certif. Heating/AC/Appliance Tech, Certif. Industrial Electronics Technology Welding Technology, Certif.

Other:

I am interested in the following:

Athletics
Campus Visitation
Residence Halls
Off-Campus Housing
Campus Life (Clubs, Activities, Intramurals, etc.)
Presidential Out-of-State Scholarship, Technical Presidential Out-of-State Tuition Waiver

Additional requested information or questions you would like answered:

How did you learn about LCSC/IIE?