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Collegiate Science & Technology Entry Program (CSTEP) Interest Form
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Please check any of the services that you are interested in and would like more information about:
Please check any of the services that you are interested in and would like more information about:
College Visits
Industry Visits
Internships
Research Opportunities
Career/Transfer Information
Academic Advice and Assistance
Community and Campus Referrals
Workshops (Resume Writing, etc)
Conferences
Job Shadowing
CSTEP Advisory Committee
Financial Assistance
Other
List Other
Personal Information
First Name
Preferred Name
Last Name
Middle Initial
JCC Student ID
Mailing Address
Mailing Address
Country
Street
City
Region
Postal Code
Is your Home Address the same as your mailing address?
Yes
No
Home Address
Home Address
Country
Street
City
Region
Postal Code
Email Address
Home Phone Number
Cell Phone Number
Birthdate
Birthdate
January
February
March
April
May
June
July
August
September
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November
December
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1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
X
Transgender Male
Transgender Female
Gender Non-Conforming/Non-Binary
Not sure/Questioning
Other
What are your preferred pronouns?
He
She
They
Other
Are you a New York State Resident?
Yes
No
Country of Citizenship?
Afghanistan
Aland Islands
Albania
Algeria
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Ashmore and Cartier Islands
Australia
Austria
Azerbaijan
Bahamas, The
Bahrain
Bangladesh
Barbados
Bassas Da India
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius, and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Clipperton Island
Cocos Islands (Keeling Islands)
Colombia
Comoros
Congo (Brazzaville)
Congo (Kinshasa)
Cook Islands
Coral Sea Islands
Costa Rica
Cote D'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Europa Island
Falkland Islands (Islas Malvinas)
Faroe Islands
Federated States of Micronesia
Fiji
Finland
Foreign/Unknown
France
French Guiana
French Polynesia
French Southern and Antarctic Lands
Gabon
Gambia, The
Gaza Strip
Georgia
Germany
Ghana
Gibraltar
Glorioso Islands
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong S.A.R.
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Jan Mayen
Japan
Jersey
Jordan
Juan De Nova Island
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau S.A.R.
Macedonia, Republic of North
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Man, Isle of
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Norway
Oman
Pakistan
Palau, the Pacific Islands of
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Spratly Islands
Sri Lanka
Sudan
Suriname
Svalbard
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tromelin Island
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis and Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zambia
Zimbabwe
Permanent Resident?
Yes
No
Race
(Please check all that apply)
Race
(Please check all that apply)
American Indian or Alaska Native
Asian
Black or African American
Middle Eastern or North African
Native Hawaiian or Other Pacific
White
Are you Hispanic or Latino?
Are you Hispanic or Latino?
Yes
No
Additional Information
Are you a first generation college student?
Yes
No
Have you ever participated in any of the following programs?
Have you ever participated in any of the following programs?
Liberty Partnership
STEP
CSTEP
EOP
CD/SEEK
Current Class Level
First Year Freshman
Second Year Senior
Do you have a completed FAFSA for the current academic year?
Yes
No
Educational Plans
How many credit hours are you currently registered for?
What is the degree program in which you are currently enrolled?
Undecided / Unsure
Accounting A.A.S.
Accounting Certificate
Addiction Studies A.A.S.
Applied Business Studies A.O.S.
BOCES - Applied Business Studies A.O.S.
Business Administration A.A.S.
Business Administration A.S.
Childhood Education A.A., Liberal Arts & Sciences
Childhood Education (Potsdam Birth to Grade 2)
Childhood Education (Potsdam Birth to Grade 6)
Computer Information Systems A.S.
Computer Information Technology A.A.S.
Computer Science A.S.
Creative Writing Concentration, Humanities & Social Sciences A.A., Liberal Arts & Sciences
Criminal Justice A.S.
Early Childhood A.A.S.
Early Childhood A.S.
Engineering Science A.S.
Health Care Management
Homeland Security A.S.
Hospitality & Tourism A.A.S.
Human Services A.S.
Humanities & Social Sciences A.A., Liberal Arts & Sciences
Individual Studies A.A.S.
Mathematics A.S.
Natural Sciences A.S. Liberal Arts & Sciences
Nursing A.A.S.
Paralegal A.A.S.
Physical Education A.S.
Psychology Concentration, Humanities & Social Sciences A.A., Liberal Arts & Sciences
Sports Management A.S.
Zoo Technology A.A.S.
What is your intended career?
My educational plans are to:
My educational plans are to:
Find employment
Continue on for a four year degree
I am not sure of my educational/career goal at this time
Other (please specify)
List Other
Yes
No
I agree that to the best of my knowledge I submitted complete, true, and accurate information on the application. By signing below I also grant permission for the Jefferson CSTEP Program to use my photograph and/or recording of my voice for any publicity related to the CSTEP Program.
Signature
Date
Date
January
February
March
April
May
June
July
August
September
October
November
December
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2000
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2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
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2021
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