BIG WEST HISTORICAL REPORT FORM        New Elig. Standards ____  Former Elig. Standards____
INSTITUTION  Cal State Fullerton                     ACADEMIC YEAR 2005-06	Sport	     
To be prepared once by a student-athlete, as a freshman or when first receiving aid or reporting for a sport.  This report must be on file as the first step for eligibility certification (Please Print.)
A.	BIOGRAPHICAL INFORMATION
Name of Student	     	     	     	
	(Last)	(First)	(Middle/Initial)
Date of Birth	Age	Social Security Number	     
Signed National Letter of Intent?  Yes    No 	Recruited?   Yes    No  	School 
B.	HIGH SCHOOL HISTORY
1.	High School from which graduated
	(High School)		(City and State)
2.	High School Graduation date (actual or expected)
		(Month)	(Day)	(Year)
3.	Did you attend any other High School?  Yes  	No   If Yes, list all other High School(s), City & State on the line below

C.	PERSONAL HISTORY SINCE HIGH SCHOOL
If you are not just out of high school, list your previous college (J.C. or 4-year) registration and attendance up to the present time.  If not in college, account for each and every year since high school graduation (i.e. military, work, etc.).  List the junior college, or university where you were first enrolled as a full-time student.
Enrollment as a full-time student in community college or university is defined by the NCAA as:  
a.	Registering for 12 or more units and attending any one of the classes one time, even if you subsequently withdrew; or
b.	Practicing or competing in any sport, even if you subsequently withdrew.	
If you attended a JC did you receive an AA degree?  Yes    No  	 Institution	Date Received
Education, Employment, Military
Service History Since High School	Show Each Semester or 
Quarter Enrolled (PT/FT)		Did you
Practice?	Did you
Compete?	Did you sign
NLI 	Did you receive  Athletic Aid?	Recruited	
Academic Yr,
(e.g. 98-99,
99-00, 01-02	
Institution (Employer,
Military, etc.)	1st
Sem/
Qtr	2nd
Sem/
Qtr	
3rd
Qtr	
Sport	
Yes or No	
Yes or No	
Yes or No	
Yes or No	Yes
or No	

											

											
I certify that all answers given by me are correct.  I understand that any false statement in this eligibility declaration will render me ineligible for further competition.  In order to determine and confirm my athletic eligibility I, the undersign, do hereby authorize consent to the release by this University to the appropriate conference and national organization and their officials any and all records including but not limited to my academic, attendance, and athletic records, which pertain to me and are necessary to determine my eligibility to compete in any intercollegiate athletic event sponsored or approved by and conducted in accordance with the rules of the appropriate athletic conference or national organization.  My social security number has been voluntarily submitted to use for identification purposes.
      Signature of Student:	Date:

D.	ELIGIBILITY INFORMATION (official use only)  
	FRESHMAN		JC TRANSFER		4-YEAR TRANSFER		4-2-4 TRANSFER           	 	 RESIDENT 
H.S. Core GPA	SAT/ACT Score	     Eligibility	5-Year Clock							                       (remaining)		(started)	(remaining)	

Institution	
Release	
AA Date	
# of Qtrs	
# of Sem	Total Units
Attempted	Total Units
Earned	Transferable
Units Earned	Transferable
GPA	
Remarks	
     	     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	     	
Total	****	****	     	     	     	     	     	     	     	
Is the student eligible this academic year for the following (Yes/No):  Financial Aid?		Competition?	        Practice?								
If the student is a transfer, list NCAA/Big West rule(s) that make him/her eligible [i.e. NCAA 14.5.5.2.10]
Institutional Representative’s Signature and Title	Ath Cert Clerk	Date	     
Faculty Athletics Representative’s Signature	Date