University Of Wyoming-EOC

Educational Opportunity Center
- Name
  
  First NameMILast Name
- Counselor
- Current Mailing Address
  
  Street Address
  
  Street Address Line 2
  
  CityST
  
  Zip
- Permanent Address is:
- 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
- Sex
- US Citizen
- Select one
  
  Other
- Social Security Number
  999-99-9999
- What is your permanent resident #?
- Military Information
- Are you a Veteran?
- Are you currently on Active Duty?
- Is your spouse on Active Duty?
- Is your parent or guardian on Active Duty?
- Ethnicity
- Do you identify yourself as Hispanic/Latino?
- Check ALL that apply
- If English is not your primary language, please indicate primary language
- Educational Information
- Current enrollment (currently attending or in courses)
- Grade
- Which high school?
- Which program?
- Do you have a certificate or an Associate's degree?
- Do you have a Bachelor's degree?
- Where do you wish to transfer?
- Name of college
- Are you CURRENTLY receiving services from another TRIO program or other federally funded program providing services similar to EOC. CHECK ALL THAT APPLY
  
  Other
- Services, please mark two that you received.
- I have completed the following:
- List Colleges:
- List Scholarships:
- Do you either of your parents have a Bachelor's (4 year) degree
- 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.
- Mother:
- Father:
- 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
- Pick one:
- If you are fully admitted to or enrolled in college, please check all that apply
- If you are younger than 18 years of age and/or enrolled in high school, please check all that apply
- 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)
- Taxable Income
- 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
- Date signed
  
  MonthDayYear
  mm-dd-yyyy
- Parent/Guardian Signature (if required)
- Date signed
  
  MonthDayYear
  mm-dd-yyyy
- I hereby certify that the signatures are made by the labeled person. Any false information may disqualify me/my child from acceptance into the program.

Educational Opportunity Center