Pima Community College-Desert Vista-SSS

New Student Application
- Legal Name:
  
  First NameM.I.Last Name
- Preferred Name: (Optional)
  
  First NameLast Name
- Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Postal / Zip Code
- Cell Phone:
  (999)999-9999
- May we Text You?
- Alternate Phone:
  (999)999-9999
- Personal Email:
  example@mail.com
- Date of Birth
  
  MonthDayYear
  mm-dd-yyyy
- Student ID #:
- Pima User Name:
- Please select one or more of the following racial / Ethnic categories to describe yourself:
- Gender
- Pronouns/Gender Identity/Anything you want us to know: (Optional)
- (If any of these options do not meet your needs, please let your TRiO SSS representative know)
- Are you a U.S. Citizen or Permanent Resident?
- Do you have a documented disability?
- Are you registered with the Access and Disability Resource Office (ADR)?
- A first-generation college student is defined as:
  - An individual neither of whose parents/guardians received a Bachelor's Degree;
  OR
  - A student who, prior to the age of 18, regularly resided with and received support
  from only one parent/guardian who did not receive a Bachelor's Degree.
- Are you a First-Generation College Student?
- Complete Either the "Independent Student Section" or the "Dependent Student Section", Based on Information from the Most Recent Tax Year:
- Are you an independent or a dependent?
- Which best describes you?
- INDEPENDENT STUDENT SECTION:
- I am an independent student (typically age 24 or older, married or emancipated; parental income is not reported on the FAFSA) complete and sign:
- Number of people in household:
- Federal Taxable Income on most recent tax year:
  Taxable Income (NOT Adjusted Gross Income: Form 1040 line 15. If taxes were not filed, please report total income from all sources.)
- Student Name:
- Student Signature:
  
  Clear
- Tax Year:
- DEPENDENT STUDENT SECTION:
- I am a dependent student (younger than 24, unmarried or not emancipated; parental income is reported on the FAFSA): parent/guardians must complete and sign:
- Number of people in household:
- Federal Taxable Income on most recent tax year:
  Taxable Income (NOT Adjusted Gross Income: Form 1040 line 15. If taxes were not filed, please report total income from all sources.)
- Parent/Guardian Name:
- Parent/Guardian Signature:
  
  Clear
- Tax Year:
- Do you already have a Bachelor's degree?
- What is your intended field of study/major?
- What are your academic plans? (Please select one)
- * If you checked any box with this symbol, you are ineligible for admittance to TRiO SSS
- Check any that apply to you. I am, or have experienced:
- Check any that you feel you need to achieve your academic goals:
- I certify that all the information on this form is true and complete to the best of my knowledge. I authorize the PCC SSS Project to obtain and review any academic, financial, disability or demographic information or documentation from staff and college instructors needed for the purposes of data collection and reporting, or progress monitoring, both at the time of my application and throughout my participation in the program.
  
  I am also aware that the personal information that is provided to the Student Support Services Program will be protected under the Family Education Rights Privacy Act of 1974.
- Student Signature
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy

New Student Application