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Place
Stamp
Here

From:  ____________________                                                                                                                                                                 
Address: __________________
City, State:  ________________
ZIP Code: _________________

                 Glendale Community College
                          Office of Admissions and Records
             1500 North Verdugo Road
  Glendale, CA 91208

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Glendale Community College Signature Form

This page must be submitted to the Admissions and Records office either in person or by mail.

I hereby apply for admission to Glendale Community College and certify under penalty of perjury that to the best of my knowledge, ALL of the statements on my application for admission are correct and complete. I also understand that willful omission or falsification to report changes in residence may result in my dismissal from the college with forfeiture of credit.

Name and Signature must match your online application

            Name: ______________________________________________________________________________
  (print)            Last                                                                             First                                                      MI

Soc. Sec. #: _____   -   ____  - _______                                                 Date of Birth _____/_____/_____

Signature: _________________________________________________ Date: _____________________

Telephone number (       ) _______ - _____________