Fscj Readmit Form – Fill Out and Use This PDF

Section I

Section II

Personal

Name _________________________________________________________			Previous Name __________________________________________
Last	First	Middle	Date of Birth	/	If Any	/
*Social Security Number ________		– _________ – __________		________________________________________
				Month	Day	Year

*In compliance with Florida Statute 119.071(5), Florida State College at Jacksonville issues this notiication regarding the purpose of the collection and use of Social Security Numbers (SSN). Florida State College at Jacksonville will collect your Social Security Number for use for legitimate business purposes which include record identiication, state and federal reporting. Providing your SSN on this application means that you consent to the use of your number in the manner described. If you choose not to provide your SSN, you will be provided an alternate identiication number. All Social Security Numbers are protected by Federal regulations and

are not to be released to unauthorized parties. Read more about the collection of Social Security Numbers in the College Catalog and on the College Web site.

Permanent Address ___________________________________________ City _______________					State ____	Zip Code ______________
	Number and Street/Apt# or P.O. Box
E-mail _______________________________________________ Telephone			(	)	(		)
					__________________________
				Home or Cell			Work
Emergency Contact _________________________ Relationship to Applicant						(	)
				______________ Telephone _________________________
	Name
Primary Language: English	Spanish	Other Country of Birth __________________________________________________________
*Country of Citizenship _____________________ Visa Type __________			Alien Resident?		Yes No Alien Number _____________

*If not a U.S. citizen, please attach a legible copy of your Visa and I-94 card or resident alien card.

Educational Plans

Intended Starting Date:

Fall (August–December)

Spring (January–May)

Summer (May–August)

Year:_______________

Check the degree or program you intend to pursue at FSCJ. Degree-seeking students must provide an oficial transcript from their high school or oficial transcript of their equivalency degree. FSCJ will request oficial transcripts from our Adult High School and from Florida Public Schools. Placement Test Scores (ACT or SAT) taken in the last two years should be sent to Assessment and Certiication, Kent Campus, 3939 Roosevelt Blvd., Room 104, Jacksonville, Florida 32205.

B.A.S. Degree Program	#_______________	A.A.S. Degree Program	# _____________
B.S. Degree Program	# _______________	Advanced Technical Certiicate	# _____________
B.S.N. Degree Program	# N200	Technical Certiicate	# _____________
A.A. Degree Program	# 1108	College Credit Non-Degree	# _____________
A.S. Degree Program	# _______________	Career Tech Programs	# _____________

Section III

Educational History
Last Term of Enrollment at FSCJ: Fall	Spring	Summer	Year___________

High School ___________________________________________City________________ State__________ Graduation Date___________

Were you on academic suspension during your last enrollment at FSCJ?

Yes

No

Unsure

Students who wish to re-enter FSCJ must complete an application for reinstatement available at any campus student success ofice.

Since you last enrolled at FSCJ, have you attended another college or university? Yes	No
If yes, list colleges and universities below:

____________________________________________________________________________________

College/University NameAddressCityStateDegree Earned

____________________________________________________________________________________

College/University Name

Address

City

State

Degree Earned

TRANSCRIPTS from each university/college attended must be submitted to Student Records at Florida State College at Jacksonville, P.O. Box 40515, Jacksonville, FL 32203-2550.