BTech Registration

BTech - Student Application / Registration

TO BE COMPLETED BY THE STUDENT

Social Security #

EMPL/STUDENT ID (8 digit CUNY Student ID Number):

Have you participated in BTech at Queensborough Community College before?:

Yes

Last Name: First Name: Middle Initial:

DOB:

Gender:

Male

Female

Address:(House/Building# & Street Address Only) Apt# Or Floor:

City: State:

Zip Code: Zip Ext:

Primary Phone:

Secondary Phone:

Student Email:

High School:

Date Entered 9th Grade:

Current Grade:

Student's High School OSIS# (9 digits # located on your ID card):

Country Of Origin / Race / Ethnicity

From which country do you associate or identify with other than this one? : If you speak another language which one?:

Ethnicity (Check one or more of the RACE(S) below with which you identify):

African American / Black	American Indian or Alaskan Native	Asian	Asian Indian
Latino / Hispanic	Native Hawaiian or other Pacific Islander	White	*Other

Other A Parent or Guardian's Highest Level of Education:

8th grade or less	Some HS	HS Graduate	Some College
College Degree	Post Graduate or Professional	Don't Know

[1] I hereby certify that all the information entered on this BTech Student Application form is accurate and complete to the best of my knowledge. I realize that failure to provide the appropriate information may affect the approval of my BTech Student Application. I understand all the information contained in this request form will be treated confidentially and will be used for institutional purposes only. [2] This form was completed by BTech Personnel.