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Pre-Academic and Community English (PACE)


Supplemental Files:
File: SSN Refusal Form.docx
Section 1: PACE Application
Page 1 of 1
Personal Information
1. 
First Name
*Required, Maximum characters allowed: 30
2. 
Middle Name
Maximum characters allowed: 30
3. 
Last Name
*Required, Maximum characters allowed: 60
4. 
E-Mail Address   
*Required, Format: x@x.xx
5. 
Date of Birth (mm/dd/yyyy)
*Required, Format: mm/dd/yyyy
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6. 

Social Security Number ( If you do not have a social security number, please enter 000-00-0000) 

*Required, Format: 123-45-6789
Mailing Address Information
7. 
Address Line 1
*Required, Maximum characters allowed: 60
8. 
Address Line 2 (Apt, Suite, or Floor Number)
Maximum characters allowed: 60
9. 
City
*Required, Maximum characters allowed: 25
10. 
State
*Required
11. 
Zip/Postal Code
*Required, Format: 12345 OR 12345-6789 OR 123456789 OR A1B 2C3
12. 

Country (only if not in US)

Mobile Phone Information
13. 

What is your mobile/cell phone number?

*Required, Format: 123-456-7890
Biographical Information
14. 

Gender 

*Required
15. 

Ethnicity

*Required
16. 

Race

*Required
17. 

Country of Birth

*Required
18. 

Native Language

*Required
Education and Employment
19. 

What is the highest level of education you completed?

*Required
Program Information
20. 

Anticipated Academic Enroll Year

*Required
21. 

Anticipated Academic Enroll Term

*Required
22. 

Primary Reason to Attend?

*Required
Certification

Student Records Disclosure

In compliance with federal FERPA regulations, the College may release the following as 'directory information' without student consent: name, program of study, date of attendance and certificate/degree awarded. Students requesting that such information be withheld must complete the appropriate form requesting specifically which directory information should be suppressed. For additional information on the Family Educational Rights and Privacy Act, please see the current Emily Griffith program catalog.

 
 
Certification of Information
 
Please read the following and type your name below: "I hereby certify that, to the best of my knowledge, the information furnished in this application is true and complete without intent of evasion or misrepresentation. I understand the above information is submitted under penalty of perjury and false or misrepresented data is sufficient cause for tuition reclassification or dismissal." "I understand that the answers to the questions in the Residency Information section of this application are required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this application is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received."
23. 
Name:
*Required
24. 
Date:
*Required, Format: mm/dd/yyyy
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