2012-13 First-year Application

For Spring 2013 or Fall 2013 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) _____________________________________________

Female
Male
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 Code Area/Country/City Code

E-mail Address ________________________________________________ IM Address ____________________________________________________

Permanent home address __________________________________________________________________________________________________________

Number & Street Apartment #

____________________________________________________________________________________________________________________________
City/Town County or Parish State/Province Country ZIP/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 & Street Apartment #

____________________________________________________________________________________________________________________________
City/Town County or Parish State/Province Country ZIP/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 college
chose not to ask that question of its applicants.
College ________________________________________________________ Deadline ______________________________________________________
mm/dd/yyyy

Entry Term:
Fall (Jul-Dec)
Spring (Jan-Jun) Do you intend to apply for need-based financial aid?
Yes
No
Decision Plan___________________________________________________ Do you intend to apply for merit-based scholarships?
Yes
No
Academic Interests _____________________________________________ Do you intend to be a full-time student?
Yes
No
____________________________________________________________ Do you intend to enroll in a degree program your first year?
Yes
No
____________________________________________________________ Do you intend to live in college housing? ______________________________
Career Interest_________________________________________________ What is the highest degree you intend to earn? _________________________

DEMOGRAPHICS
Citizenship Status ______________________________________________ 1. Are you Hispanic/Latino?
Non-US Citizenship(s) ____________________________________________
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 identify
yourself. (Check one or more and describe your background.)
Birthplace ________________________________________________________
City/Town State/Province Country
American Indian or Alaska Native (including all Original Peoples of the Americas)
Years lived in the US? ____________ Years lived outside the US? ____________ Are you Enrolled?
Yes
No If yes, please enter Tribal Enrollment Number________________

Language Proficiency (Check all that apply.) ____________________________________________________________

S(Speak) R(Read) W(Write) F(First Language) H(Spoken at Home)
S R W F H
Asian (including Indian subcontinent and Philippines)
_______________________________________________




____________________________________________________________
_______________________________________________





Black or African American (including Africa and Caribbean)
_______________________________________________




____________________________________________________________

Native Hawaiian or Other Pacific Islander (Original Peoples)
Optional The items with a gray background are optional. No information you
provide will be used in a discriminatory manner. ____________________________________________________________
Religious Preference _______________________________________________
White (including Middle Eastern)
-
US Armed Services veteran status _____________________________________ ___________________________________________________________
© 2012 The Common Application, Inc. AP-1 / 2012-13
 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 demographic
purposes 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 information
below 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):
Never Married
Married
Civil Union/Domestic Partners
Widowed
Separated
Divorced (date _________)
mm/yyyy
With whom do you make your permanent home?
Parent 1
Parent 2
Both
Legal Guardian
Ward of the Court/State
Other
If you have children, how many? _________

Parent 1 Parent 2

Mother
Father
Unknown
Mother
Father
Unknown
Is Parent 1 living?
Yes
No (Date Deceased ____________________) Is Parent 2 living?
Yes
No (Date Deceased ____________________)
mm/yyyy mm/yyyy
____________________________________________________________ ____________________________________________________________
Last/Family/Sur First/Given Middle Last/Family/Sur First/Given Middle

Former last name(s) _____________________________________________ Former last name(s) _____________________________________________

Country of birth ________________________________________________ Country of birth ________________________________________________
Home address if different from yours Home address if different from yours
____________________________________________________________ ____________________________________________________________

____________________________________________________________ ____________________________________________________________
Preferred Telephone:
Home
Cell
Work (_______) ________________ Preferred Telephone:
Home
Cell
Work (_______) ________________
Area/Country/City Code Area/Country/City Code

E-mail _______________________________________________________ E-mail _______________________________________________________

Occupation _____________________________________________________ Occupation _____________________________________________________

Employer _____________________________________________________ Employer _____________________________________________________

College (if any) ___________________________________ CEEB ________ College (if any) ___________________________________ CEEB ________

Degree _________________________________________ Year _________ Degree _________________________________________ Year _________

Graduate School (if any) ____________________________ CEEB ________ Graduate School (if any) ____________________________ CEEB ________

Degree _________________________________________ Year _________ Degree _________________________________________ Year _________

Legal Guardian (if other than a parent) Siblings

Relationship to you _______________________________________________ Please give names and ages of your brothers or sisters. If they are enrolled in
grades K-12 (or international equivalent), list their grade levels. If they have
____________________________________________________________ attended or are currently attending college, give the names of the undergraduate
Last/Family/Sur First/Given Middle institution, degree earned, and approximate dates of attendance. If more than
Country of birth ________________________________________________ three siblings, please list them in the Additional Information section.
Home address if different from yours ____________________________________________________________
Name Age & Grade Relationship
____________________________________________________________
College Attended ___________________________________ CEEB _______
____________________________________________________________
-
Degree earned _________________________ Dates __________________
Preferred Telephone:
Home
Cell
Work (_______) ________________ or expected mm/yyyy – mm/yyyy
Area/Country/City Code

E-mail _______________________________________________________ ____________________________________________________________

Name Age & Grade Relationship

Occupation _____________________________________________________ College Attended ___________________________________ CEEB _______

Employer _____________________________________________________ -
Degree earned _________________________ Dates __________________
or expected mm/yyyy – mm/yyyy
College (if any) ___________________________________ CEEB ________
____________________________________________________________
Name Age & Grade Relationship
Degree _________________________________________ Year _________
College Attended ___________________________________ CEEB _______
Graduate School (if any) ____________________________ CEEB ________
-
Degree earned _________________________ Dates __________________
Degree _________________________________________ Year _________ or expected mm/yyyy – mm/yyyy

© 2012 The Common Application, Inc. AP-2 / 2012-13

 EDUC ATION
Secondary Schools
Most recent secondary school attended ______________________________________________________________________________________________
Entry Date _________________ Graduation Date _________________ School Type:
Public
Charter
Independent
Religious
Home School
mm/yyyy mm/dd/yyyy
Address ________________________________________________________________________________ CEEB/ACT Code ___________________________
Number & Street
__________________________________________________________________________________________________________________________________
City/Town State/Province Country ZIP/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 9th grade, including academic 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)
_____________________________________________ _______________________________________________________ ____________________
_____________________________________________ _______________________________________________________ ____________________
_____________________________________________ _______________________________________________________ ____________________
Please list any community program/organization that has provided free assistance with your application process:____________________________________________
If your education was or will be interrupted, please indicate so here and provide details in the Additional Information section: ___________________________________
Colleges & Universities List all college/university affiliated courses you have taken since 9th grade and mark all that apply: taught on college campus (CO); taught on
high school campus, excluding AP/IB (HS); taught online (ON); college credit awarded (CR); transcript available (TR); degree candidate (DC).
College/University Name & CEEB/ACT Code Location (City, State/Province, ZIP/Postal Code, Country) CO HS ON CR TR DC Dates Attended Degree Earned
mm/yyyy – mm/yyyy
_________________________________ ___________________________________________





______________ _________
_________________________________ ___________________________________________





______________ _________
_________________________________ ___________________________________________





______________ _________
If you indicated that a transcript is available, please have an official copy sent to your colleges as soon as possible.

AC ADEMICS
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 are
applying and arrange for official transcripts and score reports to be sent from your secondary school and the appropriate testing agencies. Where “Best Scores” are
requested, 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
No GPA _________ Scale _________ Weighted?
Yes
No
(if available) (if available)

ACT Exam Dates: ________ ________ ________ Best Scores: _________ ______ _________ ______ _________ ______
(past & future) mm/yyyy mm/yyyy mm/yyyy (so far) COMP mm/yyyy English mm/yyyy Math mm/yyyy
_________ ______ _________ ______ _________ ______
Reading mm/yyyy Science mm/yyyy Writing mm/yyyy

SAT Exam Dates: __________ __________ __________ Best Scores: ______ __________ ______ __________ ______ __________
(past & future) mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy (so far) Critical Reading mm/dd/yyyy Math mm/dd/yyyy Writing mm/dd/yyyy

TOEFL/ Exam Dates: ________ ________ ________ Best Score: _________ ______ ______
IELTS (past & future) mm/yyyy mm/yyyy mm/yyyy (so far) Test Score mm/yyyy

AP/IB/SAT Best Scores: ________ __________________________________ _____ ________ __________________________________ _____

Subjects (per subject, so far) mm/yyyy Type & Subject Score mm/yyyy Type & Subject Score

________ __________________________________ _____ ________ __________________________________ _____

mm/yyyy Type & Subject Score mm/yyyy Type & Subject Score

________ __________________________________ _____ ________ __________________________________ _____

mm/yyyy Type & Subject Score mm/yyyy Type & Subject Score

________ __________________________________ _____ ________ __________________________________ _____

mm/yyyy Type & Subject Score mm/yyyy Type & Subject Score

Current Courses Please list all courses you are taking this year and indicate level (AP, IB, advanced, honors, etc.) and credit value. Indicate quarter classes taken in
the same semester on the appropriate semester line.
Full Year/First Semester/First Trimester Second Semester/Second Trimester Third Trimester
or additional first/second term courses if more space is needed
________________________________________ ________________________________________ _________________________________________
________________________________________ ________________________________________ _________________________________________
________________________________________ ________________________________________ _________________________________________
________________________________________ ________________________________________ _________________________________________
________________________________________ ________________________________________ _________________________________________
________________________________________ ________________________________________ _________________________________________
________________________________________ ________________________________________ _________________________________________
________________________________________ ________________________________________ _________________________________________
© 2012 The Common Application, Inc. AP-3 / 2012-13
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 or Honor Highest Level of
post-graduate (PG) Recognition
9 10 11 12 PG S S/R N I





_________________________________________________________________________________________________









_________________________________________________________________________________________________









_________________________________________________________________________________________________









_________________________________________________________________________________________________









_________________________________________________________________________________________________

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 and
paid work experience separately if you prefer. Use the space available to provide details of your activities and accomplishments (specific events, varsity letter, musical
instrument, 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 or Approximate When did you participate If applicable,
post-graduate (PG) time spent in the activity? do you plan
Summer/ Positions held, honors won, letters earned, or employer
to participate
9 10 11 12 PG Hours Weeks School School
per week per year year Break in college?

_______________________________________________________________________

Activity _________________________________________________________________________________________________________________

_______________________________________________________________________

Activity _________________________________________________________________________________________________________________

_______________________________________________________________________

Activity _________________________________________________________________________________________________________________

_______________________________________________________________________

Activity _________________________________________________________________________________________________________________

_______________________________________________________________________

Activity _________________________________________________________________________________________________________________

_______________________________________________________________________

Activity _________________________________________________________________________________________________________________

_______________________________________________________________________

Activity _________________________________________________________________________________________________________________

_______________________________________________________________________

Activity _________________________________________________________________________________________________________________

_______________________________________________________________________

Activity _________________________________________________________________________________________________________________

_______________________________________________________________________

Activity _________________________________________________________________________________________________________________
© 2012 The Common Application, Inc. AP-4 / 2012-13
 WRITING
Please briefly elaborate on one of your extracurricular activities or work experiences in the space below.

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

Please write an essay of 250 – 500 words on a topic of your choice or on one of the options listed below, and attach it to your application before submission. Please
indicate your topic by checking the appropriate box. This personal essay helps us become acquainted with you as a person and student, apart from courses,
grades, test scores, and other objective data. It will also demonstrate your ability to organize your thoughts and express yourself. NOTE: Your Common Application
essay should be the same for all colleges. Do not customize it in any way for individual colleges. Colleges that want customized essay responses will ask for them on
a supplement form.

Evaluate a significant experience, achievement, risk you have taken, or ethical dilemma you have faced and its impact on you.

 Discuss some issue of personal, local, national, or international concern and its importance to you.

 Indicate a person who has had a significant influence on you, and describe that influence.

 Describe a character in fiction, a historical figure, or a creative work (as in art, music, science, etc.) that has had an influence on you, and explain that influence.

 A range of academic interests, personal perspectives, and life experiences adds much to the educational mix. Given your personal background, describe an
experience that illustrates what you would bring to the diversity in a college community or an encounter that demonstrated the importance of diversity to you.

 Topic of your choice.

Additional Information Please attach a separate sheet if you wish to provide details of circumstances or qualifications not reflected in the application.
Disciplinary History
 Have you ever been found responsible for a disciplinary violation at any educational institution you have attended from the 9th grade (or the international equivalent)
forward, whether related to academic misconduct or behavioral misconduct, that resulted in a disciplinary action? These actions could include, but are not limited
to: probation, suspension, removal, dismissal, or expulsion from the institution.
Yes
No
 Have you ever been adjudicated guilty or convicted of a misdemeanor, felony, or other crime?
Yes
No
[Note that you are not required to answer “yes” to this question, or provide an explanation, if the criminal adjudication or conviction has been expunged, sealed,
annulled, pardoned, destroyed, erased, impounded, or otherwise ordered by a court to be kept confidential.]
If you answered “yes” to either or both questions, please attach a separate sheet of paper that gives the approximate date of each incident, explains the circumstances, and
reflects on what you learned from the experience.
Note: Applicants are expected to immediately notify the institutions to which they are applying should there be any changes to the information requested
in this application, including disciplinary history.

SIGNATURE
Application Fee Payment If this college requires an application fee, how will you be paying it?

Online Payment
Will Mail Payment
Online Fee Waiver Request
Will Mail Fee Waiver Request
Required Signature
I certify that all information submitted in the admission process—including the application, the personal essay, any supplements, and any other supporting
materials—is my own work, factually true, and honestly presented, and that these documents will become the property of the institutions to which I am applying
and will not be returned to me. I understand that I may be subject to a range of possible disciplinary actions, including admission revocation, expulsion, or
revocation of course credit, grades, and degree, should the information I have certified be false.
I acknowledge that I have reviewed the application instructions for each college receiving this application. I understand that all offers of admission are conditional,
pending receipt of final transcripts showing work comparable in quality to that upon which the offer was based, as well as honorable dismissal from the school.
I affirm that I will send an enrollment deposit (or equivalent) to only one institution; sending multiple deposits (or equivalent) may result in the withdrawal of my
admission offers from all institutions. [Note: Students may send an enrollment deposit (or equivalent) to a second institution where they have been admitted from
the waitlist, provided that they inform the first institution that they will no longer be enrolling.]

Signature _______________________________________________________________________________________________ Date ___________________

mm/dd/yyyy

Common Application member institution admission offices do not discriminate on the basis of race, color, ethnicity, national origin, religion, creed, sex,
age, marital status, parental status, physical disability, learning disability, political affiliation, veteran status, or sexual orientation.

© 2012 The Common Application, Inc. AP-5 / 2012-13