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Personal Information l Security Number or applicabie) of Ctizenship Native Language Name Pesse prnt ss t appeers in your psssponty Family Name (UPPER CASE LETTERS) Mailing Address se do rot write a PO. Box address. Express First Name Middle Name Permanent Address ff diferert from sbove) Mal wil not deliver to a PO. Box.) Proince Phone Fax Phone Fax Is there any information about yourself which you wish us to have in evaluating your qualifications for admission (honors, clubs, sports, employment, or other activities)? Sex Male Female Marital Status Single Married Will there be anyone accompanying you? Yes No Will you need a dependent l-20? Yes No If you are presenty in the United States, do you have F1 Status? Yes No If not, what kind of visa do you hold? Will you require an I-20 for a Change of Status? Travel/F-1 visa? If you are a transfer student, will you travel outside the U.S. prior to entering Berkeley?Yes No If yes, when will you travel and where should your acceptance packet be sent? Family Information s Famly Name (UPPER s Malden Name (UPPER CASE Name Waiver for Release of Information I hereby give permission to Berkeley College to release personal information obtained while in attendance at Berkeley College, and to discuss personal information with the following person(s): Address Name Release Information: Financial, Academic, Behavioral, Medical Check this box if you do not give your permission for your personal information to be released or discussed with anyone. Student Signature Parent Signature s younge o Date Personal Information l Security Number or applicabie) of Ctizenship Native Language Name Pesse prnt ss t appeers in your psssponty Family Name (UPPER CASE LETTERS) Mailing Address se do rot write a PO. Box address. Express First Name Middle Name Permanent Address ff diferert from sbove) Mal wil not deliver to a PO. Box.) Proince Phone Fax Phone Fax Is there any information about yourself which you wish us to have in evaluating your qualifications for admission (honors, clubs, sports, employment, or other activities)? Sex Male Female Marital Status Single Married Will there be anyone accompanying you? Yes No Will you need a dependent l-20? Yes No If you are presenty in the United States, do you have F1 Status? Yes No If not, what kind of visa do you hold? Will you require an I-20 for a Change of Status? Travel/F-1 visa? If you are a transfer student, will you travel outside the U.S. prior to entering Berkeley?Yes No If yes, when will you travel and where should your acceptance packet be sent? Family Information s Famly Name (UPPER s Malden Name (UPPER CASE Name Waiver for Release of Information I hereby give permission to Berkeley College to release personal information obtained while in attendance at Berkeley College, and to discuss personal information with the following person(s): Address Name Release Information: Financial, Academic, Behavioral, Medical Check this box if you do not give your permission for your personal information to be released or discussed with anyone. Student Signature Parent Signature s younge o Date