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(ddd-ddd-dddd) |
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(ddd-ddd-dddd) |
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(Must conform to the correct email format) |
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ID |
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Gender: |
Male
Female |
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STUDENT BACKGROUND INFORMATION |
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Are you
currently receiving financial aid? |
Yes
No |
If no, you are required to
submit a current copy of your Federal Income tax Return Form 1040; if you are a
dependent you must submit your parents 1040. |
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*Are you a US
Citizen or Permanent Resident? |
Yes
No |
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*E |
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*Are you receiving Public Assistance? |
Yes
No |
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Public Assistance Program: |
AFDC (Aid to Families with Dependent Children)
SSI (Supplemental Security)
RCA or RDP
GA (General Assistance)
GR (General Relief)
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ETHNICITY |
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Ethnic
Origin: |
American Indian/Alaskan
Asian
Black/African American
Hispanic/Latino
White
Native Hawaiian/Pacific Island
More Than 1 Race Reported
No Response |
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EDUCATIONAL BACKGROUND |
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Type of
Credential: |
High School Diploma
Proficiency Test
Non-Graduate
Other
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Yes
No |
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Yes
No |
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Yes
No |
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EDUCATIONAL GOALS (Check all that
apply) |
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*Educational
Goals: |
Graduate with AA/AS Degree
Occupational Certificate
Undecided
Transfer to a Four-Year University |
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Are you
registered with the Disabled Student Office?: |
Yes
No |
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CERTIFICATION |
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I have read
the requirements for the Student Support Services Program. All of the
information provided by me on this form is true and complete
to the best of my knowledge. I agree to give proof of the information that
I have given on this form, if I am asked to do so. Failure to do so may be
cause for the denial and/or cancellation from the SSS Program.
By typing my name in the space to
the right, I am verifying that all information I have given is true.
Additionally, I authorized the SSS Program to monitor my academic progress: |
Type Full
Name Here:
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