University Of Wyoming-EOC

Name *

First Name MI Last Name

Counselor *

Current Mailing Address *

Street Address

Street Address Line 2

City ST

Zip

Permanent Address is:

Same as current mailing address Different from current mailing address

Permanent Address

Street Address

Street Address Line 2

City ST

Zip

Phone 1 *

(999)999-9999

Phone 2

(999)999-9999

Email *

Date of Birth *

mm-dd-yyyy

Age

Gender *

M F

US Citizen *

Yes No

Social Security Number *

999-99-9999

What is your permanent resident #?

Military Information

Are you a Veteran? *

Yes No

Are you currently on Active Duty? *

Yes No

Is your spouse on Active Duty? *

Yes No

Is your parent or guardian on Active Duty? *

Yes No

Ethnicity

Do you identify yourself as Hispanic/Latino? *

Yes No

Check ALL that apply *

Asian Black or African American American Indian or Alaska Native Native Hawaiian or other Pacific Islander White Two or more races

If English is not your primary language, please indicate primary language

Educational Information

Current enrollment (currently attending or in courses) *

Current high student Individual without a GED/HiSET or high school diploma Current GED/HiSET High School/GED/HiSET graduate Previous college student Potential college transfer student (earned a Certificate or two-year degree) Current College Student

Grade

9 10 11 12

Which high school?

Which program?

Do you have a certificate or an Associate's degree?

Yes No

Do you have a Bachelor's degree?

Yes No

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 *

GEAR UP TRIO Upward Bound (UB) TRIO Student Services (SSS) on college campuses TRIO Talent Search TRIO Upward Bound Math Science (UBMS) None

Services, please mark two that you received.

Financial Aid Advising/Scholarships Admission Advising/Fee Waiver Academic Advising ACT Waiver Career Exploration Financial and Economic Literacy HiSET/GED Assistance or Referral College Entrance Prep Social Service Agency Referral

I have completed the following:

FAFSA Admissions at the following colleges Scholarships

List Colleges:

List Scholarships:

Do you either of your parents have a Bachelor's (4 year) degree

Yes No

If your parents are divorced or separated, please indicate the educational level for the parent you lived with the most.

Educational Opportunity Center