Applicant's full name:_____________________________age____gender____
Are you legally blind: yes___no___
A doctor's or
qualified professional's verification statement is required.
Applications will not be processed without this information.
Permanent California residence address:
_____________________________________________________________
street city zip telephone
Summer address: (if different)
_____________________________________________________________
street city zip telephone
School address: (if different)
_____________________________________________________________
street city zip telephone
E-mail address: ________________________________
Cumulative all college grade point average:______________________________
High School attended:__________________________________________
name city state
List previous colleges attended: (years attended and total units completed)
____________________________________From_____to_____Units_____
____________________________________From_____to_____Units_____
____________________________________From_____to_____Units_____
College now attending:__________________________________________
name city state
College you will attend this summer:_______________________________
Total number of units completed:__________________________________
Total number of units carried this term:__________________________
Total number of units you will carry next Fall:________________________
(If your school measures course work in hours, please provide the total units you will receive.)
State your Subject Major:________________________________________
Are you a client of the California Department of Rehabilitation? YES __ NO __
If yes, please provide the name of your Rehabilitation Counselor. Your answer will not effect the validity of your application. ____________________________
PROVIDE A STATEMENT (NOT MORE THAN 200 WORDS) GIVING YOUR PURPOSE IN UNDERTAKING COLLEGE WORK AND YOUR VOCATIONAL GOALS.
YOU MAY ALSO MENTION YOUR INTERESTS AND AVOCATIONS:
ALL APPLICATIONS MUST BE ACCOMPANIED BY A COMPLETE LIST OF TRANSCRIPTS.
IF YOU ARE A MEMBER OF THE CALIFORNIA COUNCIL OF THE BLIND, WE WOULD APPRECIATE A LETTER OF RECOMMENDATION FROM THE PRESIDENT OF YOUR CHAPTER. IF YOU ARE NOT A MEMBER BUT YOU KNOW A MEMBER, WE WOULD APPRECIATE A LETTER OF RECOMMENDATION FROM THAT PERSON. YOU MAY ALSO SEND LETTERS FROM TEACHERS OR OTHERS. EVEN IF YOU HAVE APPLIED PREVIOUSLY, PLEASE PROVIDE UPDATES TYPEWRITTEN INFORMATION. IF YOU WOULD LIKE TO CONTACT THE CCB CHAPTER NEAR YOU, PLEASE CALL THE CCB OFFICE AT 916-441-2100 OR 1-800-221-6359 MONDAY THROUGH FRIDAY BETWEEN 10:00 a.m. AND 4:00 p.m. TO OBTAIN CONTACT INFORMATION.
IN ORDER TO PROCESS YOUR APPLICATION, THIS APPLICATION, TRANSCRIPTS AND RECORDS MUST BE SUBMITTED TO THE CALIFORNIA COUNCIL OF THE BLIND OFFICE BY JUNE 15, 2010.
HOWEVER, IF TRANSCRIPTS ARE NOT AVAILABLE AT THAT TIME, YOU MAY SUBMIT THEM BY NO LATER THAN JULY 15, 2010.
WE WILL ATTEMPT TO ARRANGE A TELEPHONE INTERVIEW. ACCURATE SUMMER TELEPHONE NUMBERS AND ADDRESSES ARE VITAL TO THE PROCESSING OF THIS APPLICATION.
STUDENT SIGNATURE:______________________________DATE:_____________