THE COMMUNITY COLLEGE OF BALTIMORE COUNTY CATONSVILLE CAMPUS   Mortuary Science Program STUDENT MEMORANDUM FOR MORTUARY SCIENCE (PLEASE PRINT AND COMPLETE BEFORE SEEING ADVISER) Today's Date____________________                                            Brian Burke, Program Director - Mortuary Science The Community College of Baltimore County Catonsville Campus Mortuary Science Program 800 S. Rolling Road - D205 Catonsville, MD  21228 Name:____________________________________________________________    Last First Middle    (Former) Address:_______________________________________   Number and Street         _______________________________     ___________________________ City and State        Zip Phone (H) (     )_____________     Phone (W)(    )_____________     Student ID Number:_____________________                                                                                  Academic Level:  (Circle One)     High School Diploma     G.E.D.     A.A.     B.S.     M.S.     Ph.D.     Other______________ (Expected) Date of Entry into Mortuary Science Program:____________________________ Which best describes your educational history? (Check One)   1) _________ High school vocational/technical background   _________ High school general education background   _________ G.E.D. (High school equivalent)       2) _________ 0-12 college credits:     CCBC Catonsville______ Other________ Where?___________     13-30 college credits:     CCBC Catonsville______ Other________ Where?___________     31-60 college credits:     CCBC Catonsville______ Other________ Where?___________     61-120 college credits:     CCBC Catonsville______ Other________ Where?___________     120+ college credits:     CCBC Catonsville______ Other________ Where?___________       3) ________ I have completed my apprenticeship. State?________________   ________ I am currently serving my apprenticeship. My apprenticeship officially began on ________________ (date).     Employer:____________________________________________     Address:_____________________________________________     Telephone:(______)___________________   This is my first and only apprenticeship. Yes_______ No_________       4) Why do you want to work in funeral service?  What attracted you to this profession?   _____________________________________________________________   _____________________________________________________________   _____________________________________________________________   _____________________________________________________________     5) I have attended another mortuary school. Yes ________ No_______   If yes, where?__________________________________________     6)  I am currently enrolled in the Mortuary Science Program at CCBC Catonsville. Yes_____  No_____        If yes, when did you begin your studies? (Date)_____________     7)  I am a veteran of the Armed Forces.   Yes_____ No_____   I am eligible for veteran's benefits. Yes_____ No_____     8) I may need financial aid while attending classes at CCBC Catonsville. Yes_____ No_____     9) In what state do you seek licensure? __________________________________________   I know the requirements in that state.  Yes_____ No_____     10) Check the classes you have successfully completed.  If you have transferred and have been credited by the registrar with an equivalent class from another institution, circle the class name. ____ ENGL 101 ____ BIOL 130 ____ MORS 121 ____ SPCM 101 ____ BIOL 245 ____ MORS 122 ____ PSYC 101 ____ BIOL 252 ____ MORS 131 ____ Diversity Elective ____ MORS 106 ____ MORS 132 ____ Science Elective ____ MORS 101 ____ MORS 141 ____ Math Elective ____ MORS 102 ____ MORS 142 ____ Wellness & Health ____ MORS 111 ____ MORS 151   or Info Lit/Tech ____ MORS 113 ____ CINS 101 ____ ACCT Elective ____ MORS 115                                  ______________________________________________  _____________________ Signature         Date                                                                                               Revised August 2006