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Personal Information:

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* First Name:

* Last Name:

* Birthdate:

* Email Address:

Cell Phone Number:

Gender:

Ethnic Origin:

What race do you identify as:

Select your American Indian or Alaska Native Ethnic Group: (hold the Ctrl button to select more than one option)

Select your Asian Ethnic Group: (hold Ctrl button to select more than one option)

Select your Black or African American Ethnic Group: (hold the Ctrl button to select more than one option)

Select your Hispanic or Latino Ethnic Group: (hold the Ctrl button to select more than one option)

Select your Native Hawaiian or Pacific Islander Ethnic Group: (hold the Ctrl button to select more than one option)

Select your White/Caucasian Ethnic Group: (hold the Ctrl button to select more than one option)

Are you a Veteran or a Dependent of a Veteran:

Education Information:

What is the name of the current or last school you attended:

Academic Information:

ctcLink/Student ID:

* Which quarter do you plan to attend:

* What type of credential do you want: (pick all that apply)

* What career pathway are you interested in: (pick all that apply)

Other Information:

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