CLEVELAND STATE UNIVERSITY

Online Undergraduate Application Form For Admissions

PERSONAL INFORMATION

Name Diamond Caeli Rose

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Last First Middle Former or Maiden

Social Security Number 372-15-1499 Gender

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Male ✔ Female
Are you a U.S. Citizen? ✔ Yes No

y
Alien Registration Visa

op
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ID Number Issue Date Type Country of Citizenship

Ohio Residency: County Cuyahoga

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✔ I am currently living in Ohio and have lived in Ohio I am currently living in Ohio, but I have not lived in Ohio

tC
for the past 12 consecutive months or more. (IS) for the past 12 consecutive months.
I am currently attending college/university outside of Ohio, I am not a resident of the state of Ohio. (OS)
but I am a resident of the state of Ohio.

Ethnicity
Are you Hispanic or Latino? ✔ Yes No
an
Select one or more of the following: Black/African American American Indian/Alaskan Native Asian
Native Hawaiian/Other Pacific Islander ✔ White

Are you a United States Veteran? Yes ✔ No

ic

Date of Birth 10/30/1991 Email Address roziray@gmail.com

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month day year
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Home Phone 440-684-9189 Cell Phone Work Phone

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I would like to receive important news and information from Cleveland State via text message. Yes ✔ No

Home Address 892 Lander Road

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Street Apt # Additional Street Information

Highland Heights Cuyahoga Ohio 44143 United States

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City County State Zip Country

Mailing Address
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Street Apt # Additional Street Information

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City County State Zip Country

Emergency Contact Relationship

Name Shari DeCarlo
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First Last ⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯

Address 892 Lander Road

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Street Additional Street Information
Highland Heights Ohio 44143 United States
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City State Zip Country

Emergency Phone Number 440-684-9189 Second Phone Number

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Has your Mother/Father/Guardian earned a four-year Is your Mother/Father/Guardian a graduate of Cleveland

bachelors degree from a college or university? State University?
Mother/Guardian: ✔ Yes No Father/Guardian: Yes ✔ No Mother/Guardian: Yes ✔ No Father/Guardian: Yes ✔ No
Applicant’s name mapped here (First
Caeli Rosename / Middle name / Diamond
Last name)

ENROLLMENT PLANS

Applicant Type Intended Major/Program of Study

Undecided. Still exploring my options.
✔ Domestic International ⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯

When do you expect to enroll at CSU? Type of Admission

✔ Degree State of Ohio Teaching Licensure
Fall Semester 2011
⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯ Non-Degree Cleveland State Certificate

y
op
Will you have completed a bachelor’s degree prior to your expected enrollment term at CSU? Yes ✔ No

Do you plan to live on campus? Yes No Would you like information about Financial Aid? ✔ Yes No
✔ Undecided

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Have you ever pled guilty or been convicted of a criminal Have you ever been dismissed, suspended or placed on
offense or have charges pending against you at this time? probation by any other college, university or high school
Yes ✔ No for a NON-ACADEMIC reason? Yes ✔ No

PREVIOUS EDUCATION
an
High School Graduate or GED? High School Graduate HS Grad Date or Date GED Completed 06/05/2010
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Name of High School MAYFIELD HIGH SCHOOL City MAYFIELD State OH

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HS CEEB Code 361325
⎯⎯⎯⎯⎯⎯⎯⎯
ic

Which English Language Proficiency exams have you taken or do you plan to take (International applicants only)?
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TOEFL Score IELTS Score Michigan Language Test

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Date Taken or Expected Date Taken or Expected Date Taken or Expected

TOEFL Score IELTS Score Score

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Date Taken or Expected Date Taken or Expected

Education History

Name of Institution LAKELAND CMTY COLLEGE School Code 1422

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City KIRTLAND State Ohio Country United States

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Are you currently enrolled in this college or university? ✔ Yes No

Less than 30 semester
Dates of Attendance: From 08/2010 To 05/2011 Hours Earned hours
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Degree Awarded or Expected Yes ✔ No If Yes, Associate’s Degree Bachelor’s Degree Other
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Name of Institution School Code

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City State Country

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Are you currently enrolled in this college or university? Yes No

Dates of Attendance: From To Hours Earned

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Degree Awarded or Expected Yes No If Yes, Associate’s Degree Bachelor’s Degree Other
⎯⎯ ⎯⎯ ⎯⎯⎯⎯⎯⎯⎯
Applicant’s
Caeli name mapped here (First
Rosename / Middle name / Last name)
Diamond

Name of Institution School Code

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City State Country

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Are you currently enrolled in this college or university? Yes No

Dates of Attendance: From To Hours Earned

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Degree Awarded or Expected Yes No If Yes, Associate’s Degree Bachelor’s Degree Other
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op
Name of Institution School Code
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City State Country

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Are you currently enrolled in this college or university?

Dates of Attendance: From

⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯ tC Yes

To
No

⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯
Hours Earned
⎯⎯⎯⎯
an
Degree Awarded or Expected Yes No If Yes, Associate’s Degree Bachelor’s Degree Other
⎯⎯ ⎯⎯ ⎯⎯⎯⎯⎯⎯⎯

Name of Institution School Code

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City State Country

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Are you currently enrolled in this college or university? Yes No

Dates of Attendance: From To Hours Earned

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Degree Awarded or Expected Yes No If Yes, Associate’s Degree Bachelor’s Degree Other
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PERSONAL STATEMENT--Please discuss how Cleveland State University will help you achieve your personal and /or career goals. If
your education has not been continuous, please account for your time out of school.

⎯⎯⎯⎯
Cleveland ⎯will
State ⎯⎯ be⎯ ⎯⎯attribute
a great ⎯⎯⎯ to⎯
my⎯ ⎯⎯⎯
personal ⎯ ⎯⎯
success as ⎯ ⎯⎯⎯
a student ⎯a ⎯
and ⎯⎯The
person. ⎯⎯ ⎯⎯
broad ⎯ ⎯⎯
selection of ⎯ ⎯⎯
course ⎯⎯⎯
offerings ⎯programs
and ⎯⎯ ⎯⎯ are⎯ ⎯⎯⎯to
impressive ⎯me,
⎯⎯ and⎯ ⎯⎯
show how⎯much
CSU has to give to me as a student. As a person interested in both furthering my abilities in foreign language (whether or not I decide to major in that area) and traveling abroad, attending
⎯⎯
CSU ⎯be⎯a⎯
will ⎯asset
vital ⎯⎯to⎯ my ⎯future.
⎯⎯Whether
⎯⎯⎯I ⎯ ⎯⎯
decide to ⎯ ⎯⎯
major ⎯⎯⎯
in health ⎯⎯⎯
sciences as I⎯ ⎯⎯⎯intended,
originally ⎯⎯⎯or⎯ in⎯ ⎯⎯⎯which
linguistics, ⎯⎯⎯ I am⎯currently
⎯⎯⎯considering,
⎯⎯⎯⎯in⎯ ⎯⎯
terms of⎯ ⎯⎯
cost, ⎯⎯and
location
opportunities, what CSU has to offer fits my needs and exceeds my expectations.
⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯
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⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯
⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯

Signature Date of Signature

⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯ ⎯⎯⎯⎯⎯⎯⎯⎯