Northwest Mississippi Community College-SSS

SSS TRiO Academic Program

Student Application

Northwest Mississippi Community College Student Support Services program is federally funded by the U.S. Department of Education. The mission of SSS is to provide academic and personal support to help participants successfully graduate and/or transfer to a 4-year university. Eligibility is based on federally defined criteria:
1. Income 2. Family background 3. Disability
Do you plan to transfer to a 4-year university after leaving Northwest?*

YesNo
- Name*
  
  First NameMiddle InitialLast Name
- Social Security Number*
  999-99-9999
- NWCC Student ID*
- Home Address*
  
  Street
  
  Street Address Line 2
  
  CityState
  
  Zip
- Dorm Address
  
  Dorm Name
  
  Street Address Line 2
  
  CityState / Province
  
  Dorm Room Number
- Email Address*
  example@example.com
- Cell Number*
  (999) 999-9999
- Home Phone Number
  (999) 999-9999
- DOB*
  
  MonthDayYear
  mm-dd-yyyy
- Major*
- Race*
- Gender*
  
  MaleFemale
- U.S. Citizen*
  
  YesNo
- Veteran*
  
  YesNo
- ESL (English second language)*
  
  YesNo
- Does your mother/legal guardian have a four year degree?*
  
  YesNo
- Does your father/legal guardian have a four year degree?*
  
  YesNo
- Who did you live with until your 18th birthday?*
  
  MotherFatherBoth
- If you have a different situation (Foster care, ward of the state, etc.) please explain:
- Do you have a documented disability?*
  
  YesNo
- If so, is the information filed with NWCC Disability Services?*
  
  YesNo
- Verified
- Have you participated in Student Support Services before?*
  
  YesNo
- If so, what year?
- I hereby affirm that all of the information provided on this application to be true and complete to my knowledge; I understand that any false information given may result in the loss of SSS participation opportunity. My signature below allows Student Support Services to have access to the following: ACT scores, transcripts, Financial Aid records, documentation of disability (if applicable), records of admission to all colleges, and progress reports from instructors.
- Signature*
  
  Clear
- Date*
  
  MonthDayYear
  mm-dd-yyyy
- You may complete this section yourself or we can assist you. If you would like
  assistance, please sign below & skip the rest of the Income section
  
  I verify that the financial information on this form is current and accurate.
- Sign Here*
  
  Clear
- If you did NOT sign above, please answer the questions below :
- For Financial Aid Purposes, are you considered?
  
  IndependentDependent
- Student’s Adjusted Gross Income
- Number in household claimed on student’s income tax?
- Parent’s Adjusted Gross Income?
- You can also provide: (if you did not sign or complete the section above)
- A signed U.S. tax return
  
  Browse Files
  
  Cancelof
- Verification of family income from another governmental source
  
  Browse Files
  
  Cancelof
- A signed statement regarding income of independent student or parent
  
  Browse Files
  
  Cancelof
- List Financial Aid Awarded
- Please verify that you are human*
- Should be Empty: