Eastern Oklahoma State College-SSS

Program Application

Eastern Oklahoma State College • www.eosc.edu/trio
1301 West Main • Wilburton, OK 74578 • 918.465.1825
Johnston Hall 112 in Wilburton • Information Center in McAlester
The following information is requested to determine your eligibility for program services. Please answer each question. This information will be kept confidential and used only as outlined in the participant agreement.

Personal Information
Name*

(first)(middle)(last)
Address*

Street or PO box

Street Address Line 2

CityState

Zip
Cell Phone
(999)999-9999
May We Text You? (study tips, reminders, events, etc.)

YesNo
Home Phone
(999)999-9999
Email*
example@example.com
Social Security #
999-99-9999
Student ID #
Date of Birth*

MonthDayYear
mm-dd-yyyy
Gender (optional)

MaleFemale

Signature
- I understand that if I am receiving financial aid, TRiO SSS staff will obtain my financial information. If I am not receiving financial aid, I will provide a copy of my most recent tax return.
- I understand that I will have access to the TRiO SSS program at no additional cost beyond my regular tuition and fees as an EOSC student.
- I understand that the TRiO SSS staff may confer with my instructors at any time concerning my progress and grades.
- I understand that the TRiO SSS staff are not licensed counselors and students with ongoing personal issues will be referred to professional counselors.
- I understand that I must participate in the TRiO SSS activities that my SSS advisor assigns to me based upon my needs assessment and by full filling this requirement, I will be eligible to apply for the SSS grant aid scholarship.
Affidavit of Truth Statement

The information provided on this form is, to the best of my knowledge, accurate and true.
Student's Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy

Submit
Please verify that you are human*
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