Lakeland Online Application

Personal Email:

Email Address:

Confirm Email Address:

Personal Information:

IDENTIFICATION

First Name (Official): 60 characters

Last Name (Official): 60 characters

Middle Initial:

Former/Maiden:

Social Security Number:

Date of Birth (mm/dd/yyyy): / /

ADDRESS

Street Address (30 characters):

Apt. No:

City:

State:

Zip:

County:

Have you resided in Lake county for the last 6 months?

Yes No

Have you resided in Ohio for the last 12 months?

Yes No

PHONE

Primary Phone: 999-999-9999

Primary Phone Type:

Secondary Phone:

Secondary Phone Type:

Enrollment Information:

Select Degree / Certificate:

US Military Service Veteran:

Yes No

Select Type:

Educational Background:

EDUCATION

Have you attended another college/university since you last attended Lakeland?

Yes No

List all college(s) YOU attended since last attending Lakeland: Please submit your official transcript(s) to Admissions.

College Attended (25 chars):

College State/Location:

Degree Earned:

Year Earned:

Citizenship/Ethnicity:

CITIZENSHIP

U.S. Citizenship Status:

Resident Card Number: A copy of your card is required as part of the Admissions Criteria.

Visa Type:

Registration Date:

Selective Service:

State Statute requires that all Ohio resident male students complete the following form.
Failure to do so may result in the student being charged the out-of-state tuition rate.

Selective Service Number:

Date Registered (mm/dd/yyyy):

Selective Service Exemption:

I certify that I am not required to be registered with Selective Service. I qualify for exemption for the following reason:
	I am under the age of 18
	I am over the age of 26
	I am with the armed forces of the United States excluding training in the reserve or national guard unit.
	I am a permanent resident of the Trust Territory of the Pacific Islands or the Northern Mariana Islands and I am not a citizen of the U.S.
	I am a non-immigrant alien lawfully in the U.S. in accordance with Section 101 (A) (15) of the Immigration and Nationality Act U.S.C 1161, as amended.
	No Exemption

Enrollment Alerts:

I consent to receive enrollment text alerts from Lakeland Community College.You may uncheck the box to decline text alerts.

I VERIFY THAT THE ABOVE INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE.
I affirm that I am the actual returning student and that submitting false information is illegal and against institutional policy.

Enter text shown above:
Values are case sensitive

Identify the object in the picture above:

Lakeland Community College

Returning Student Application