Paris Junior College-EOC

INTAKE APPLICATION

Please complete the following application form to be eligible for project services.

For any questions or assistance, email trioeoc@parisjc.edu or call 903-782-0353.
Social Security Number*
999-99-9999
Name*

First NameMILast Name
E-mail Address*
example@example.com
Telephone Number*
(999)999-9999
Address (Number and Street include Apt. Number) NO P.O. Box*

Street Address

Street Address Line 2

CityState

Zip code
In what county do you currently reside?*
Other county, if applicable
Date of Birth*

MonthDayYear
mm-dd-yyyy
Current Age*
Gender*

FemaleMale
Are you a U.S. Citizen?*

YesNo
If no, are you a legal resident?*

YesNo
PRC#*
What is your race? (check all that apply)*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic/Latino of any raceWhiteNative Hawaiian or other Pacific Islander
Are you Hispanic/Latino?*

YesNo

Number in Family (include self)*

	Adults	Children
Number in Family (current household) include self

What is your current marital status?*

SingleMarriedDivorcedSeparated
What is your employment status?*

Full-TimePart-TimeUnemployed
Do you receive any of the following income source(s): (mark all that apply)

Welfare (TANF)Food Stamps (EBT)Social Security (SSI)Unemployment BenefitsVeteran BenefitsOther
Last year, what was your family's "TAXABLE" income?* Taxable income is your gross income, minus any exemptions or deductions. Your 2022 taxable income can be found on IRS form 1040, line 11b.*
Did you receive a High School Diploma?*

YesNo
Did you receive a GED?*

YesNo
From where did you get your diploma/GED? (list school name, city & state)*
Year HS/GED Received?*
Are you currently a senior in a High School Diploma program?*

YesNo
Are you currently working on getting your GED?*

YesNo
What school/program are you currently attending to get your diploma/GED?*
In what grade did you drop out of high school?*
Do you have the desire to pursue an education beyond high school?*

YesNo
Are you currently attending college or a vocational training program?*

YesNo
Where do you currently attend college? (institution, city & state)
Have you ever attended college or a vocational training program?*

YesNo
Where did you last attend college or a training program? (list school name, city & state)*
When did you last attend college? (year only)*
Do you have a college degree?*

Associate of Arts or Science Degree (AA/AS)Bachelor of Arts or Science Degree (BA/BS)I do not have a college degree
Did either parent (natural or adoptive) with whom you regularly resided with and received support from, graduate from a 4-year college, prior to your 18th birthday?*

Parent 1 (mother)Parent 2 (father)BothNeither
Is anyone in your family a Veteran of the U.S. Armed Forces? (mark all that apply)*

SelfSpouseParent/GuardianNone of the above
Is anyone in your family active-duty military? (mark all that apply)*

SelfSpouseParent/GuardianNone of the above
Will you be applying for VA benefits?

YesNo
Mark all that apply

HomelessEx-offenderDisabledActive-duty militaryFormally in Foster Care Ward of Court
What services are you interested in receiving? (check all that apply)*

Academic/Career GuidanceAdmissions/College ApplicationsFinancial Aid Applications/FAFSATesting/GED AssistanceFinancial Literacy/Budget PlanningCollege Transfer AssistanceTutoring/Study SkillsOther
Have you ever participated in any of the following TRIO programs? (check all that apply)*

Educational Opportunity CenterUpward Bound/Math & ScienceEducational Talent SearchVeteran's Upward BoundGear UpMcNairStudent Support ServicesNone of the above
Where do you plan to attend college?*

Paris Junior College - Paris CampusParis Junior College - Greenville CenterParis Junior College - Sulphur Springs CenterNortheast Texas Community CollegeTexas A&M University at CommerceUndecidedInterested in a GEDOther
When do you plan to enroll in college or a GED program?*

Fall (August - December)Spring (January - May)Summer I or II (June/July)Other
Signature

Clear