Admissions & Student Recruitment

Non Degree Seeking Student Application

“Transitory” DS Credential Only Student

(This form must be mailed to CSU San Bernardino Admissions & Student Recruitment

as per directions posted at:

For all DS Credential Only Students)

Date: ______Circle Term Applying For: Summer – Fall – Winter - Spring

SSN: ______Circle Campus: San Bernardino or Palm Desert

(for the “all online” ECTS courses please circle “San Bernardino”)

Legal First and Last Name: ______

(Name as it appears on your SSN card)

Current Address: ______

City: ______State: ______Zip: ______

Permanent Address:______

City: ______State: ______Zip:______

Home Telephone ( ) ______Daytime phone ( ) ______

Email address: ______

Date of Birth______Sex M____ F____

MonthDay Year

Desired Program

DS Credential Only (for ECTS courses only) / Information available at
Orb e-mail Dr. Ron Pendleton

County of Residence

San Bernardino ______Riverside ______Other county______

Country of Citizenship (all must answer) ______

Citizenship Status (all must answer--please circle one)

Y- U.S. citizen

I – Immigrant I-551 (“green card”) Date issued ______

MonthDayYear

O-Other Visa (specify) ______Date ______

MonthDay Year

R- Refugee/AsylumF-F visa (student) J- J visaN- None of the above

If you were born outside the U.S., what year did you to move tothe U.S.? ______

High School Attended: ______

______

High School City High School State

HS Graduation month & year______GED Date: ______Ceeb: ______

Do you have a Bachelors Degree? Yes or No

If yes please indicate the year awarded and name and location of the university:

______

Circle your ethnic identity code (optional) ______

1-American Indian or Alaskan native; tribe

2-Black, non-Hispanic, including African American

3-Mexican American, Mexican, Chicano

4-Other Latino, Spanish-origin, Hispanic

5-Other Asian8-Other

D-Decline to state9-No response

Places you lived before your present stay in California:

From: _____To: _____State/Country: ______Parent/Guardian (lived with)______

From: _____To: _____State/Country: ______Parent/Guardian (lived with)______

___If you are under the age of 19, questions above pertain to your parent/guardian

___If you are age 19 or over, questions above pertain to self

Citizenship Status ______

What state do you consider your home? ______

Do you claim California Residency? Yes or No

What date did your stay in California begin? ______

Birth Location______

Have you lived in California continuously since birth? Yes or No

Signed ______

Applicant’s signatureDate

Signed at ______

County

Return to:

CSU San Bernardino Office of Admissions

5500 University Parkway

San Bernardino, CA 92407

Attn: DS Credential Courses Only

NOTE: Please attach a check or money order (made out to CSUSB) for the $55.00 application processing fee. For more information please contact the Office of Admissions & Student Recruitment at (909) 537-5188.

For Office Use Only:

Program: UTRN or PTRN Date of Application Data Entry:______