LSSC is the first college or university you will attend.

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1 LSSC X-ID: Application for Admissions Application Type (select only one) Bachelor's Program Student First Time in College Student Readmit Student Transfer Student Transient Student from non-florida or private Florida College or University LakeHawk College Preview event High School Senior Day 1 General Information Name as it appears on Social Security Card (legal name) You are a student who has already earned an AA or AS degree or equivalent and wish to pursue an LSSC Bachelor's degree. LSSC is the first college or university you will attend. You were previously enrolled at LSSC but have not enrolled for longer than two semesters. LSSC is not the first college or university you have attended. You have previously attended another college or university. You are a degree or a non-degree seeking student. You are a student at a non-florida institution or a private Florida institution and do not plan to complete your degree at LSSC. You are a student that attended and completed a Lakehawk College Preview event and received an application fee waiver You are a student that completed and attended a High School Senior Day and received an application fee waiver. Please include your high school name and the date of the event here: Have you ever been enrolled in the LSSC Upward Bound program? Yes No Have you ever been enrolled in the LSSC Educational Talent Search program? Yes No Please print legibly in blue or black ink Last Name First Name Middle Name Suffix (Jr., Sr., II) Mailing Address City Florida County State Zip/Postal Code Social Security Number* Country Telephone Number (home) * All SSN s are protected by federal regulations (FERPA) and are never released to unauthorized parties. Telephone Number (work) Telephone Number (mobile/cell) ( ) ( ) ( ) Address (REQUIRED) Secondary Address Birth Date Mo / Day / Yr Gender p Female p Male Are You Hispanic or Latino* p Yes p No Race: (select one or more)* p American Indian or Alaska Native p Black or African American p Native Hawaiian or Other Pacific Islander p Asian p White * Information related to race and ethnicity is required by the U.S. Department of Education for reporting purposes and will not be used to determine eligibility for admission. List all previous names: When do you plan to enroll at Lake-Sumter State College? Fall Term Spring Term Summer Term Year What is your home campus? Leesburg South Lake Sumter I agree to receive text messages from LSSC in the event of an emergency. Yes No I agree to receive text messages from LSSC regarding general college information. Yes No U.S. Citizen: Country of birth What is your native language? p English p Spanish p Other LSSC ID: ID generated by: Record of campus: Data entry date: Office Use Only Processed by: Non U.S. Citizen: Country of birth Country of citizenship What is your native language? p English p Spanish p Other Visa Type/Status p Dependent p Exchange Scholar p Non-immigrant visa for spouse p Resident Alien p Student p Temp Worker p Tourist Other (please list) Visa or Resident Alien Number Visa or Resident Alien Number Issue Date M/D/Y Visa or Resident Alien Number Expiration Date M/D/Y

2 2 Planned Course of Study Select your degree or certificate type and identify your academic program. (see page 4) (select one) A.A. (Associate of Arts) Program name Program number A.S. (Associate of Science) Program name Program number A.A.S. (Associate of Applied Science) Program name Program number CERT (Technical Certificate) Program name Program number B.A.S. (Bachelor of Applied Science) Program name Program number Non-degree seeking Program name Program number Note: Some LSSC academic programs are limited access and have specific admissions requirements. Admission to LSSC does not guarantee acceptance to a limited access program. Note: To receive financial aid you must select an aid-eligible degree or certificate program. For more information please visit lssc.edu/finaid. Please identify your intended meta-major. (check one) Arts, Humanities, Communication & Design Business Education Health Sciences Industry, Manufacturing & Construction Public Safety Science, Technology, Engineering & Mathematics Social & Behavioral Sciences and Human Services Please indicate the year you plan to graduate from LSSC Do you plan to transfer to UCF upon the completion of your degree at LSSC? Yes No Are you planning to complete a Bachelor's degree at a Florida public college or university? Yes No If yes, which college or university? 3 High School Information Which of the following have you completed or plan to complete? (check one) Standard high school certificate of completion* Standard high school diploma Special high school diploma* GED (state issued high school equivalency diploma; English version) Home Education Program Affidavit (must complete the LSSC affidavit) Certificate of completion - Met all requirements except FCAT Provisional: I am at least 18 years of age and have not received a standard high school diploma or GED* High school presently attending or last attended: Name of High School Graduation Date (Mo/Day/Yr) City County State Country High School Equivalent Diploma (G.E.D.) * Students admitted with a special diploma, certificate of completion (earned prior to 2003), or under provisional status must earn a G.E.D. before pursuing an Associate in Arts Degree, Associate in Science Degree, Associate in Applied Science Degree, or certificate program. State Issuing G.E.D. Date Issued (Mo/Day/Yr) 4 Previous College Information By indicating that you have attended another higher education institution you are certifying that you have graduated from high school with a standard diploma or have earned a General Education Diploma (GED). List all institutions/dates attended: Enter official name of institution. No abbreviations. College/University Name and Campus Dates Attended From To Mo/Yr Mo/Yr City State Country Use additional sheet of paper if necessary. If you listed a Lake Technical Center in the space above, do you plan to transfer articulation credits? Yes No (must be a program identified as an articulation program between Lake Tech and LSSC)

3 Application for Classification as Florida Resident for Tuition Purposes 5 Residency & Additional Information Residency Information I am a Florida resident for tuition purposes. I understand that I must provide two forms of residency documentation to LSSC. Yes No Yes No If a non-resident, enter your state of residence: Note: All students will be admitted as non-florida residents for tuition purposes. If you wish to be considered a Florida resident and pay in-state tuition, you must submit the required residency documentation in person or through the U.S. Mail to the LSSC Admissions and Records Office. All students, regardless of residency status, must submit an LSSC Residency Affidavit. Additional Information Enter the additional information requested. This additional information is required to process your application. Disability Support Services: Students with documented disabilities may self-identify and request accommodations by contacting the campus Office for Students with Disabilities: Web: PooleR@lssc.edu Phone: (352) Regardless of your age, please check the box that corresponds to your parent or guardian 1's education level below: Parent or Guardian 1: Less than high school, no diploma High school diploma or equivalent/ged Credit certificate business, trade school, or technical Some college, no degree Associate degree or two-year degree Bachelor s or four-year degree Graduate (e.g., masters, doctorate, etc.) or professional degree (e.g., law, psychology, medicine, pharmacy, etc.) Unknown Regardless of your age, please check the box that corresponds to your parent or guardian 2's education level below: (If no second parent/guardian raised you, please check "No second parent or guardian raised me") Parent or Guardian 2: Less than high school, no diploma High school diploma or equivalent/ged Credit certificate business, trade school, or technical Some college, no degree Associate degree or two-year degree Bachelor s or four-year degree Graduate (e.g., masters, doctorate, etc.) or professional degree (e.g., law, psychology, medicine, pharmacy, etc.) Unknown No second parent or guardian raised me Please indicate the letter that corresponds to your current status with the United States Armed Forces in the box to the right: Active duty personnel Eligible dependent (spouse/child) Active member of the National Guard Active member of the Reserves Prior military service (Veteran), service dates unknown Prior military service (Veteran), service began before 9/11/2001 Prior military service (Veteran), service began on or after 9/11/2001 No military history Unknown/No Response Are you a Career Pathways (Tech Prep) student? Have you passed a CLEP, IB or AP exam? Yes No Yes No How did you learn about LSSC? Family Friend Website HS Visit Newspaper LSSC Event TV HS Counselor LSSC Staff Other If you have other information that is important for us to know to process your application, enter it here:

4 6 Emergency Contact Information Last Name First Name MI Relationship to Student Phone 7 Student Rights and Responsibilities In accordance with the Family Educational Rights and Privacy Act, a student s educational records are the sole property of the students and cannot be released without student permission. More information is available in the official college catalog and on the LSSC website. I understand that this application is for admission to Lake-Sumter State College and is for the term within this application. I also understand and agree that I will be bound by the college s regulations concerning admissions requirements, academic deadlines, and the LSSC Student Code of Conduct. I authorize LSSC to release directory information, test scores and transcripts to colleges to assist with transfer processes. I certify that all the information provided in this application is correct and accurate, and I understand that to make false or fraudulent statements within this application or residency statement may result in disciplinary action, denial of admissions and invalidation of credits or degrees earned. Application Fee: (Bachelors, Transfer, Transient), $0 (Re-admit) Your application will be reviewed within 3-5 business days. Upon final processing of your application, you will receive an Admissions acknowledgement letter that will include your LSSC Student Identification Number (X-ID). I have read all of the information above and hereby apply for admission to Lake-Sumter State College. I certify that all information provided by me is accurate and complete. I certify that I have reviewed Lake-Sumter State College's Notification of Social Security Number Collection and Usage policy. I certify that as a condition of my admission, I will not engage in the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance during enrollment at Lake-Sumter State College. I agree to the release of any transcripts or test scores to this institution, including but not limited to any SAT, Achievement Test, and ACT score reports that this institution may request from other institutions, the College Board, or ACT. I hereby authorize Lake-Sumter State College to transfer my student records from any Florida school or college previously attended that can transmit records electronically to Lake-Sumter State College. I further agree to allow my academic records to be transferred electronically to any educational institution of my choice. While attending Lake-Sumter State College, I agree to uphold all federal and state laws, county and municipal ordinances and all College rules, regulations, policies and procedures. I also certify that I have answered all questions on this application truthfully and accurately, and that all information provided is complete. Failure to fully disclose information in response to all questions on this application (and, if applicable, the student disclosure of disciplinary and/or criminal convictions) may result in immediate denial of admission and/or expulsion/ suspension from a course, program, or the College. Signature Date

5 WHERE FUTURES SOAR META MAJORS Arts, Humanities, Communication & Design Business Education Health Sciences Industry, Manufacturing & Construction Public Safety Science, Technology, Engineering & Mathematics Social & Behavioral Sciences and Human Services BACCALAUREATE PROGRAM OF STUDY ASSOCIATE IN APPLIED SCIENCE (A.A.S) ASSOCIATE IN ARTS (A.A.) TECHNICAL CERTIFICATES B.A.S. Organizational Management 290 A.A. General Studies ASSOCIATE IN SCIENCE (A.S.) A.S. Business Administration A.S. Computer Information Technology A.S. Criminal Justice Technology A.S. Engineering Technology A.S. Health Information Technology A.S. Industrial Management Technology** A.S. Nursing LSSC offers the A.S.N. as a Limited Access Program, which cannot be selected at time of application. Please select program 190-A.A. General Studies with a Health Sciences Meta Major to complete the required prerequisites necessary to apply for the A.S. in Nursing. ** The Industrial Management Technology AS Degree requires prior completion of a 900+ clock hour PSAV Certification to enroll. Hours must be verified in order to register for this program. LEESBURG CAMPUS 9501 US Highway 441 Leesburg, FL A.A.S. Electrical Distribution Business Management* Business Operations* Business Specialist* Cert Chemical Lab Specialist Cert Criminal Justice Technology Specialist Cert Digital Forensics Cert Electrical Distribution Technology Basic Cert Electrical Distribution Technology Advanced Cert Engineering Technology Support Specialist* Cert Healthcare Informatics Specialization* Cert Information Technology Analysis* Cert Medical Information Coder/Biller Cert Medical Office Management NON-DEGREE SEEKING & LINKAGE PROGRAM Non-degree Employment related* Non-degree Personal Enrichment* Non-degree Transient student* Dental Hygiene linkage to Valencia College* *program not eligible for financial aid S UMTER CENTER 1405 County Road 526A Sumterville, FL SOUTH LAKE CAMPUS 1250 N. Hancock Road Clermont, FL LSSC.edu Visit our website at or call Admissions/Records: LSSC is a public community college supported by the State of Florida. LSSC is an EA/EO institution. Lake-Sumter State College is committed to non-discrimination based on race, color, sex, ethnicity, gender, national origin, age, disability, genetic information, marital status, veteran status, religion, sexual orientation, political affiliation and pregnancy. This commitment applies in all areas to applicants, visitors, students, faculty, administrators, staff, and others affiliated with the College.