Rose State College-SSS

STUDENT APPLICATION
Name*

First NameMILast Name
Date of Birth*

MonthDayYear
mm-dd-yyyy
SS Number
999-99-9999
Student ID*
Mailing Address

Street Address

Street Address Line 2

CityState

Zip
Cell Phone
(999)999-9999
Alternate Phone
(999)999-9999
Rose E-mail*
example@example.com
Preferred E-mail
example@example.com
US Citizen*

YesNo
If not a citizen, are you a permanent resident?

YesNo
Do you meet the residency requirements for federal financial aid?

YesNo
Thank you so much for your interest in our program, unfortunately you do not meet the eligibility requirements set forth by the U.S. Department of Education.
Sex*

MaleFemale
Ethnicity: Are you Hispanic or Latino?*

YesNo
Race (check all that apply)*

African-AmericanAmerican Indian or Alaskan NativeAsianCaucasianNative Hawaiian or Pacific IslanderOther
Marital Status

SingleMarriedDivorcedOther
Number of Dependents

Ages of Dependents

Secondary Education*

HS DiplomaHS Equivalency ExamNeither
HS Grad Year or HS Equivalency Exam Year
Have you attended any colleges other than Rose State?

YesNo
List the other institutions you have attended
Do you plan to earn a certificate or Associates degree?

YesNo
Major
Do you plan to pursue a bachelor’s degree?

YesNoUndecided
If yes, where?
Did one of your parents graduate from college with a Bachelor’s degree?*

YesNo
Have you completed the FAFSA?

YesNo
Are you receiving federal financial aid?

YesNo
You will be asked to provide financial documentation (most current federal tax return) to determine program eligibility.
Do you have a disability?

YesNo
If yes, please describe
You will be asked to provide documentation to determine program eligibility.
How did you hear about TRIO Student Support Services?
Have you previously participated in a TRIO program?

YesNo
If yes, which program?
Student Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
For more information call (405) 733-7379 or visit www.rose.edu/content/academics/student-services/student-support-services