Southeastern Oklahoma State University-EOC

Educational Opportunity Center

Please complete this application and an EOC staff member will reach out to you for assistance.

Personal Information
Name*

First NameMiddle Initial Last Name
Previous Names

First NameLast Name
Date of Birth*

MonthDayYear
mm-dd-yyyy
Age*
Social Security Number (Required only for FAFSA filing):
999-99-9999
Gender*

FemaleMale
Gender
Mailing Address*

Mailing Address

Street Address Line 2

CityState

Zip
County of Residence*
Telephone #*
(999)999-9999
Email Address*
example@example.com
Highest grade completed*

6789101112GEDVocational/Tech School2 Yr College
Have you attended college previously?*

YesNo
If yes, when/where?
Are you in a GED or alternative educational class now?*

YesNo
Primary Language Spoken:
Please select your race below:*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or Latino of any raceNative Hawaiian or Pacific IslanderTwo or more racesWhiteI prefer not to answer
Native American tribe (if applicable)
Did either of your parents (biological, step or adoptive) graduate from a 4-year college?*

YesNo
Marital Staus*

SingleMarriedDivorcedWidowedSeparated
If separated, please give date of separation

MonthDayYear
mm-dd-yyyy
Are you a U.S. Citizen or a Permanent Resident?*

YesNo
If you’re not a citizen or permanent resident, do you intend to become a permanent resident (documentation may be requested)?

YesNo
Alien Registration # (for eligible non-citizens/permanent residents only)
A-_________
Are you a veteran of the U.S. military or on active duty or reserve?*

YesNo
Are you the dependent child or spouse of someone on military active duty or reserves?*

YesNo
Are you participating in another TRIO or federally-funded program such as another EOC, Talent Search, Upward Bound or GearUP?*

YesNo
Please tell us how you heard about our program.*
Please mark below which one best describes your current educational status:*

I am a high school senior (12th grade)I graduated high school or earned my HiSET/GED diplomaI am currently enrolled in a HiSET/GED program or alternative school programI did not complete high school or a HiSET/GED programI have an Associate’s DegreeI attended college or vocational school before but did not complete/graduateI am currently enrolled in college or vocational schoolI am in college and interested in transferring to another school
EOC Services
What services may our program assist you with? Please mark all that apply:

I am needing help with my FAFSA and/or other financial aid forms, or finding scholarships and other aidI am needing help with applying to college or vocational schoolI am needing help with admissions testing or academic adviceI am needing help finding my career interestsI am needing help with financial literacy, student loan counseling or default assistanceI am needing help with finding a college or vocational school that’s right for meI am needing help with finding a HiSET/Ged program and preparing for testingI am needing help finding other resources to assist me
Please fill in what services you are seeking that are not listed above:
Financial Information
Applicants over 24 years of age: Please complete the questions below regarding household size and income.

Applicants under 24 years of age: You may be required to submit your parent’s income and their signature. If a parent is not available, parent’s documentation may be requested by your EOC Academic Advisor. If you think you are considered an independent student (married, parent, in foster care, veteran, etc.), talk to your EOC Academic Advisor about whose income to report.
What was your (or your parent’s) adjusted gross income last year? (Amount from line 11 of your 1040 tax form). If you know the income amount, write it here
If you are unsure of the exact amount, please mark below the range last year’s income.
Last year's income information*

$0 - $21,870$21,871 - $29,580$29,581 - $37,290$37,291 - $45,000$45,001 - $52,710$52,711 - $60,420$60,421 - $68,130$68,131 - $75,840 +
How many people are in your household?*
Source of income*

Wages/salarySSI/SSDITANFUnemploymentOther
Taxable income
$__________
Supported by*

Self and/or spouseParent/Guardian
Number of dependents in household your support*
Signature(s)
Applicant and/or parent/guardian signatures below certify the information provided on this application is true and correct to the best of my knowledge, and authorizes EOC to release or request information related to the Applicant’s educational processes, including financial aid to and from 1)institutions and entities; 2) parents/guardians of the Applicant; and 3) the National Student Clearinghouse for the purpose of tracking Applicant’s post-secondary education program.
Applicant Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent Signature (Required if applicant is under age 18)

Clear
Date

MonthDayYear
mm-dd-yyyy
CERTIFICATION/PERMISSION
I certify that the above information is accurate and complete to the best of my knowledge. The Educational Opportunity Center Staff has my permission to receive copies of education records and other materials necessary for participation in their services. I further understand that all my records will be kept in confidence and in accordance with the Privacy Act of 1984. Permission is granted to send enrollment and financial aid information to the Educational Opportunity Center of Southeastern Oklahoma State University, 425 W. University Blvd., Durant, OK 74701.
Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
How can EOC assist you today? (mark all that apply)*

Filling out FAFSA, financial aid forms, discussing grants or student loans, or other financial literacy or financial aid assistanceCompleting a career assessment, learning styles inventory, or other interest inventoryAcademic and/or admissions assistance, discussing college or vocational school options, or school re-entry assistanceHelp with locating referrals for other resourcesOther
List area(s) of occupational interest - jobs or careers you have considered, and would like education or training to pursue:
My educational goal is to*

Obtain my GED or high school equivalency certificateAttend a trade/vocational school for license or certificationAttend a 2-year college for a certificate/license/Associate's degreeObtain a Bachelor's degree (or higher)
College or Vocational School most interested in attending
Location of College/School
If undecided, please check here

undecided
The EOC is funded by a grant from the United States Department of Education. Southeastern Oklahoma State University, in compliance with Title IV of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972 and Section 503 and 504 of the Rehabilitation Act of 1973, and the ADA, 1989, does not discriminate on the basis of race, color, national origin, sex or handicapped status in any of its policies, practices, or procedures. Any student needing special accommodations, due to a physical, mental or learning disability, should contact the EOC Guidance Specialist. It is the responsibility of each participant to request assistance due to a disability. Accommodations cannot be guaranteed without adequate advance notice.
EOC MEDIA RELEASE FORM (OPTIONAL):
I do hereby consent and authorize Southeastern Oklahoma State University’s EOC program to take photographs of me to be copyrighted, published, reproduced, exhibited, or circulated, with or without advertising sponsorship, for any and all purposes, including publications and advertisements of all kinds in all media and/or the official SE website; and do hereby assign to said parties all right, title, and interest to such material. I further release Southeastern Oklahoma State University from any and all claims for damages for libel, slander, invasion of the right of privacy or any other claim based on the use of said materials.
Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

EOC Services

Financial Information

Signature(s)