Southeastern Oklahoma State University-EOC

Name *

First Name Middle Initial Last Name

Previous Names

First Name Last Name

Date of Birth *

mm-dd-yyyy

Age *

Social Security #

999-99-9999

Gender *

Female Male

Mailing Address *

Mailing Address

Street Address Line 2

City State

Zip

County of Residence *

Telephone # *

(999)999-9999

Email Address *

example@example.com

Highest grade completed *

Have you attended college previously? *

Yes No

If yes, when/where?

Are you in a GED or alternative educational class now? *

Yes No

Ethnicity *

American Indian/Alaskan Native Tribe Asian Black/African American Caucasian/White (non-hispanic) Hispanic/Latino Native Hawaiian/Pacific Islander Middle Eastern Multiracial Prefer not to answer

Native American tribe (if applicable)

Did either of your parents graduate from a 4-year college? *

Yes No

Marital Staus *

Single Married Divorced Widowed Separated

If separated, please give date of separation

mm-dd-yyyy

U.S. Citizen or Legal Resident? *

Yes No

Alien Registration # (for eligible non-citizens/permanent residents only)

A-_________

Are you a veteran, guard or active duty? *

Yes No

Military spouse or dependent? *

Yes No

Are you receiving services from another TRIO program (EOC, talent search, student support services)? *

Yes No

Please tell us how you heard about our program or who referred your *

Last year's income information *

0-19,140 19,141-25,860 25,861-32,580 32,581 – 39,300 39,301 – 46,020 46,021 – 52,740 52,741 – 59,460 59,461 – 66,180 +

Source of income *

Wages/salary SSI/SSDI TANF Unemployment Other

Taxable income

$__________

Supported by *

Self and/or spouse Parent/Guardian

Number in household (include self) *

Number of dependents in household your support *

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 *

mm-dd-yyyy