Application for Admission
Blackburn CollegeBachelor of Arts Degree Program
Business Management
Program for students with an A.S. degree or A.A.S. degree in Management who wish to earn a baccalaureate degree in business. / Before enrollment process can be completed:
1) This form must include your written signature
2) Student must request Official copy of high school or GED transcript be mailed to LCCC
3) All Official transcripts from other colleges
/ Program offered at:
Lewis & Clark Comm. College
5800 Godfrey Road
Godfrey, IL 62035
Social Security Number
/Name: Last First Middle
/ Previous Name(s)ð MR
ð MS
ð Other ______/ Street Address: / Home Area Code & Phone
Work Area Code & Phone
City or Town / State / Zip Code / County / Cell Area Code & Phone
Citizenship or Visa (Check one)
ð U.S. Citizen
ð In U.S. on a Visa – Exp. Date ______
What type of Visa? ______
Country of Citizenship: ______
ð Permanent Resident / Date of Birth
/ / / Sex
ð Male
ð Female / E-mail Address
Racial Ethnic Group (response optional)
ð Asian Pacific Islander ð Hispanic American
ð Indian American ð White American
ð Black American ð Non-Resident Alien
L &C Degree Goal (if applicable, to be earned during junior level of studies)
ð Program Name Associate in Science Program Code 1701A
ð Program Name Associate in Applied Science – Management Program Code 5085A
Enrollment Status
ð Attended another college previously
ð Attended LCCC previously / Are you a high school graduate? ð Yes ð No
Date (Month & Year) you graduated ______
Name of High School ______
City & State ______/ If you are not a high school graduate have you completed the GED test?
ð Yes ð No
ð Not Applicable
Term You Plan to Enroll (check one)
ð Fall (year) ______
ð Spring (year) ______
ð Summer (year) ______/ Residency
ð In District
ð Out of District: District #______
ð Out of State
ð Foreign Country
List all Colleges Attended (most recent first)
Name of Institution / City / State / Dates of Attendance / Degree Obtained
A. I understand that computerized student records are filed by social security number and I hereby authorize the use of my social security number for that purpose.
B. I understand that admission to the college does not insure entrance into a particular course or program of studies. There may be additional requirements to certain programs. / C. I understand that all transcripts received by LCCC become the property of LCCC. The LCCC transcript and others received may be released to Blackburn College but will not be released to any other third party except for statistical reports.
Signature Date