University Of Wyoming-EOC

Educational Opportunity Center
- Name*
  
  First NameMILast Name
- Counselor*
- Current Mailing Address*
  
  Street Address
  
  Street Address Line 2
  
  CityST
  
  Zip
- Same as current mailing addressDifferent from current mailing address
- Permanent Address
  
  Street Address
  
  Street Address Line 2
  
  CityST
  
  Zip
- Phone 1*
  (999)999-9999
- Phone 1 type
- Phone 2
  (999)999-9999
- Phone 2 type
- Email*
- Date of Birth*
  
  MonthDayYear
  mm-dd-yyyy
- Age
- MaleFemale
- YesNo
- U.S. CitizenU.S. Non-citizen NationalU.S. Permanent ResidentOther
- Social Security Number *
  999-99-9999
- What is your permanent resident #?
- Military Information
- YesNo
- YesNo
- YesNo
- YesNo
- Ethnicity
- YesNo
- AsianBlack or African AmericanAmerican Indian or Alaska NativeNative Hawaiian or other Pacific IslanderWhiteTwo or more races
- If English is not your primary language, please indicate primary language
- Educational Information
- Current high school studentIndividual without a GED/HiSET or high school diplomaCurrent GED/HiSETHigh School/GED/HiSET graduatePrevious college studentPotential college transfer student (earned a Certificate or two-year degree)Current College Student
- 9101112
- Which high school?
- Which program?
- YesNo
- YesNo
- Where do you wish to transfer?
- Name of college
- GEAR UPTRIO Upward Bound (UB)TRIO Student Services (SSS) on college campusesTRIO Talent SearchTRIO Upward Bound Math Science (UBMS)NoneOther
- Financial Aid Advising/ScholarshipsAdmission Advising/Fee WaiverAcademic AdvisingACT WaiverCareer ExplorationFinancial and Economic LiteracyHiSET/GED Assistance or ReferralCollege Entrance Prep and TutoringSocial Service Agency Referral
- FAFSAAdmissions at the following collegesScholarships
- List Colleges:
- List Scholarships:
- YesNo
- Do either of your parents have a Bachelor’s Degree/4-year College Degree? If your parents are divorced or separated, please indicate the educational level for the parent you live with the MOST and “N/A” for the other.
- YesNoN/A
- YesNoN/A
- If your parents are divorced or separated, please indicate the educational level for the parent you lived with the most.
- If you are 18 or over, not a high school student, and not fully admitted to or enrolled in college, please indicate your taxable income range below
- A) I am 18 or over, not a high school student, and not fully admitted to or enrolled in collegeB) I am fully admitted to or enrolled in college (currently taking courses)C) I am younger than 18 years of age and/or enrolled in high school
- I am age 24 or older by December 31 of this year.I am married (or separated, but not divorced).I have legal dependents (other than a spouse or children) who live with me and who receive more than half of their support from me.I have children who receive more than half their support from me.I am a veteran of the Armed Forces of the United States or am currently serving on active duty in the Armed Forces for other than training purposes.I have been an orphan, in foster care, or a ward of the court after age 13.I am in legal guardianship as determined by a court of my legal residence at time of determination and/or an emancipated minor.I am a youth in transition or an unaccompanied youth.I have been determined to be an independent student by the financial aid office at my college.
- I am married (or separated, but not divorced).I have legal dependents (other than a spouse or children) who live with me and who receive more than half of their support from me.I have children who receive more than half their support from me. .I have been an orphan, in foster care, or a ward of the court after age 13.I am in legal guardianship as determined by a court of my legal residence at time of determination and/or an emancipated minor.I am a homeless person or an unaccompanied youth.
- If you DO NOT meet any criteria above, you will need a parent/guardian to verify family taxable income range below in order to receive services as an income-eligible participant.
- Please indicate your taxable income range (not gross income) based on your previous year’s taxes.
  (EOC Coordinators have taxable income worksheets to assist you in quickly calculating taxable income. You can also find taxable income listed on tax form 1040 Line 11b)
- $0 - $23,940$23,941 - $32,460$32,461 - $40,980$40,981 - $49,500$49,501 - $58,020$58,021 - $66,540$66,541 - $75,060$75,061 - $83,580Above $83,581
- Family Size? (Total number of dependents claimed on taxes, including yourself)*
- Certification: To the best of my knowledge, the information provided is accurate and complete. I certify that I am 18 years of age or older, competent to complete the certification of citizen/eligible non-citizen status, and that the information provided in this application is true and accurate, under penalty of perjury. I authorize Educational Opportunity (EOC) to request and receive records related to my academic and degree status, financial aid status, and higher education registration and enrollment records for the purposes of tracking student academic progress, recordkeeping, and reporting purposes. I authorize EOC to use this information for purposes of public relations, media events, recruitment, editorials, and possible referrals to other agencies for which I may be eligible.
- Participant Signature*
  
  Clear
- Date signed
  
  MonthDayYear
  mm-dd-yyyy
- Parent/Guardian Signature (if required)
  
  Clear
- Date signed
  
  MonthDayYear
  mm-dd-yyyy
- Yes

Educational Opportunity Center