University Of Nebraska-Omaha-SSS

UNIVERSITY OF NEBRASKA AT OMAHA
TRIO PROJECT ACHIEVE APPLICATION

Today's Date*

mm-dd-yyyy

Date of Birth*

mm-dd-yyyy

Student's First and Last Name*

First NameLast Name

NUID

Gender

FemaleMalePrefer Not To Answer

Current Address*

Street Address

Street Address Line 2

CityState

Zip Code

Preferred Phone*

(999)999-9999

Preferred Email*

example@example.com

Start Term*

FallSpring

Class Standing*

FreshmanSophomoreJuniorSenior

Are you a U.S. Citizen*

YesNo

Are you a permanent resident of the U.S.

YesNo

Residency # (if applicable)

Have you been previously enrolled in Project Achieve?*

YesNo

Please enter start date:

mm-dd-yyyy

Please enter end date:

mm-dd-yyyy

Ethnic Background

Family Income: (Income information is required from the independent student, parent/guardian of dependent student, or financial aid office.)

Actual family income (actual/estimate)*

Size of Household (including yourself)*

Have either of your parents/guardians received a 4-year degree?*

YesNo

Do you have a disability? If so, please select the list below. (This question is optional)

Intended major while at the University of Nebraska at Omaha:*

Intended minor while at the University of Nebraska at Omaha:

Support Services Needed (check all that apply)

Are you currently employed:*

YesNo

Where?

On-campusOff-campus

How many hours a week?

Are you receiving financial aid at this time?*

YesNo

If not, do have plans to apply for financial aid?

YesNo

In what career field would you like to work after graduation?

Where do you see yourself in five years? *

Are you interested in continuing your education after graduation?*

YesNo

In your own words, why do you want to participate in Project Achieve? *

Have you taken a Math Placement Exam?*

YesNo

If not, when do you plan to take a Math Placement Exam?

Have you taken an English Placement Exam?*

YesNo

If not, when do you plan to take a English Placement Exam?

I understand that Project Achieve staff can assist me in achieving my goals only if I fulfill my obligation to take advantage of the serves provided and that failure
to meet my responsibilities can result in a suspension or termination from the program.

I hereby attest that the information provided is true to the best of my knowledge and I authorize Project Achieve to verify the information I have provided on my
application and to access information related to my attendance, academic performance, graduation as well as other information necessary for the proper delivery of the program services. I also understand that the information in my Project Achieve file may be viewed by other agencies to which the Project Achieve program is accountable. I authorize Project Achieve to include information about and images of me in Project Achieve marketing materials.

Signature*

Date Signed*

mm-dd-yyyy