Elizabeth City State University-SSS-Application Form

Name*

First NameMILast Name

Student ID Number

Date of Birth

mm-dd-yyyy

Campus or Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

ECSU Student Email Address*

example@example.com

Home/Cell Phone

(999)999-9999

Permanent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Gender

MaleFemale

U.S. Citizen

YesNo

Race/Ethnicity (For statistical purposes only)

EMERGENCY CONTACT INFORMATION

Name

First NameLast Name

Phone Number

(999)999-9999

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Relationship

EDUCATIONAL ASSESSMENT

Major(s)

Minor(s)

Classification

Program Assessment

Have you previously participated in any of the following programs? (lf yes, please check which one)

At what school or institution?

ELIGIBILITY INFORMATION

Name of Mother/Guardian

First NameLast Name

Mother's Highest Education

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of Father/Guardian

First NameLast Name

Father's Highest Education

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

READ THE FOLLOWING STATEMENT AND SIGN

I agree that the information on this application is correct to the best of my knowledge. lf any information changes on this form while I am a part of this program, I will notify the Student Support Services Progam immediately. I understand that in order for the Student Support Services Program to accurately assist me, I will be honest in communicating all my information that may be needed.

Applicant Signature

Date

mm-dd-yyyy

Personal Statement: Please write a brief statement of your personal goals and career aspirations, as well as the most likely complication that might delay your graduation.