Chesapeake College Admissions Application - Free Download
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Chesapeake College Admissions Application
P.O. Box 8, Wye Mills, MD 21679
Web address: www.chesapeake.edu
(410) 822-5400; 758-1537; 228-4360 Fax #: 410-827-5878
TTY Users: Call via Maryland Relay
Please print clearly. Use black or blue ink. Check the appropriate boxes and complete entire application. No application fee is
required. Please return completed application to: Chesapeake College, Office of Admissions, P.O. Box 8, Wye Mills, MD 21679.
PERSONAL INFORMATION
Social Security
Number:
Social Security numbers are used by the College to ensure the integrity of
student records and to meet federal government reporting requirements. They
are also needed for Scholarships and Financial Aid.
Last Name (Legal): First Name: Full Middle Name:
Other Names (i.e. maiden):
Date of Birth:
(month/day/year)
Current Address
Street Number and Name/Apt. # :______________________________________________________________________________________________ P.O. Box #: __________________________________
City: State: Zip Code:
How long have you lived at your current address
Less than 3 months 3 months or more
If less than 3 months, list previous address:
Street Number and Name/Apt. # :___________________________________________________________________________________ P.O. Box #: __________________________________
City: State: Zip Code:
Length of time at previous address:
Months: Years:
County of Residence:
005 Caroline 017 Queen Anne’s Other MD County (write below):
009 Dorchester 020 Talbot ___________________________
014 Kent 040 Out-of-State 099 Out-of-Country
Phone Numbers:
Home: ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
Cell: ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
Email:_____________________________________________________________________________________________________________________________________________
I certify that the following information is correct and complete to the best of my knowledge:
I am a dependent of and live with my parent(s) or guardian(s) at the Current Address given above. Yes No
I was claimed by my parents in the previous tax year. Yes No
If yes, what is their legal state of residence _____________________________________ If Maryland, what county ______________________________________
Gender: Male Female
How many hours do you spend in a typical 7-day week:
Working for pay: None 1-5 hours 6-10 hours 11-20 hours 21-30 hours More than 30 hours
Providing care for dependents living with you: None 1-5 hours 6-10 hours 11-20 hours 21-30 hours More than 30 hours
ETHNICITY INFORMATION
The following information is gathered for purposes of meeting state and federal agency requirements. This information is not used for admission to
Chesapeake College.
Part 1: Please select the group which most closely represents you: Hispanic/Latino (HIS) Non-Hispanic/Latino (NHS)
Part 2: Please select one or more of the following groups which most closely represents you:
American Indian or Alaska Native (AN)
Asian (AS)
Black or African American (BL)
Native Hawaiian or Other Pacific Islander (HP)
White (WH)
FOR OFFICIAL USE ONLY
Date: ________ Semester: _________
Stud. ID #: ______________________
