Zane State College-SSS

ZANE STATE COLLEGE
Student Support Services Program Application

EDUCATIONAL INFORMATION
Date of High School Graduation

Month Day Year
mm-dd-yyyy
OR

Received GED
Name of High School Attended
Current Math Level
Current English Level
Program of Study
Current Enrollment Status

Full-time Part-time
Have you attended college elsewhere?

YES NO
If YES, Where?
Are you transferring credits to ZSC?

YES NO
If YES, How many?

INCOME VERIFICATION
Number in Household:
Your Family's TAXABLE INCOME
Your TAXABLE INCOME
OR

My Family DID NOT File Income Taxes
*Please submit your family’s most recent income tax return, showing taxable income (Line #10 on Form 1040).
Parent/Guardian Signature

Clear
Date Signed

Month Day Year
mm-dd-yyyy

AUTHORIZATION
I authorize the SSS Program to obtain, copy, review, and discuss my records, including:
- High School Transcript
- Transcripts from Other Colleges
- Financial Aid Records
- Standardized Test Scores
- Course Registration for Each Semester
- Academic Progress
- Final Grades and Transcripts
- Disability Documentation
I authorize use of my name and photograph to be published in Student Support Services’ publications. I also certify that all of the above information is correct. Completion of the application does not guarantee acceptance into the program. By typing my name below, I am certifying the authenticity and accuracy of the information in this document.
Student Signature

Clear
Date Signed

Month Day Year
mm-dd-yyyy

ADDITIONAL DOCUMENTS
In addition to submitting the Program Application, submit the following documents:
Copy of your and/or your family’s most recent income tax return or tax transcript:
Copy of your ZSC ID card
Copy of your State-Issued ID card
Office: 740.588.4114
TRIO - STUDENT SUPPORT SERVICES
Zane State College
College Hall, Room C148
1555 Newark Road, Zanesville, OH 43701
Email: jaddoanum@zanestate.edu

TRIO Student Support Services is a 100% federally funded by the Department of Education Grant to serve 144 participants.