Near Completer Intake Form | CSUN Connections

Name

First Last

LACCD Student ID

Student Information

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Best Time to Reach You

Email

Preferred Communication Method (Email/Phone)

Are you currently working?

If yes, please indicate your regular work schedule (ex: Monday- Friday, 9am – 5pm)

Do you have dependent children or other caretaking responsibilities?

LACCD Status

Financial Aid Status

Degree Information

Student on track to earn (AA/AS/ADT/Credential) in (Program)

Remaining degree requirements

Campus Referrals

CalWorks

CARE

EOP&S

Puente/Umoja

Tutoring Center

Library (library card?)

Graduation Plan

Student tasks (Ex: Apply for readmission, submit additional transcripts, apply for graduation, pay diploma processing fee, pay previous balance, etc)

Other

Advisor’s tasks (Ex: Have transcripts evaluated, request diploma processing fee waiver, request student debt forgiveness, connect student to appropriate staff at campus units identified above, etc)

Next Advising Appointment (Date, Time, and Location)

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