Delta Sigma Theta Incorporated-EOC-Intake Form

The Maryland Educational Opportunity Center (MEOC), a program of the national office of Delta Sigma Theta, Inc. funded by the U.S. Department of Education, provides free postsecondary planning assistance to eligible program participants.
Documentation of citizenship, income and residency will be requested and used only for statistical purposes.

Name *

First MI Last

Would you prefer to fill in your full SSN or just the last 4 digits *

Full SSN Last 4 digits

Soc. Sec. No. *

999-99-9999

Last four digits of Soc. Sec. No. *

9999

Address

Street Address

Street Address Line 2

City State

Zip Code

Home Phone

(999)999-9999

Cell/Work Phone

(999)999-9999

Email *

example@example.com

Date of Birth

mm-dd-yyyy

Age *

Gender

Male Female

Citizenship *

U.S. Citizen Eligible Noncitizen

Alien Registration Number

Marriage Status

Married Single Separated Divorced Widow/er

Ethnicity

Hispanic/Latino American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White More than one race

Physical or Learning Disability

Military Status

Veteran Active Duty Military Parent Active Duty Military Spouse Active Duty Military

Family Size *

Taxable Income Range for 2019 (If you are a dependent, do both.) *

	You	Parents
$0 — $ 0
$1 — $19,320
$19,321—$26,130
$26,131—$32,940
$32,941—$39,750
$39,751—$46,560
$46,561—$53,370
$53,371—$60,180
$60,181—$66,990
$66,991—Over

Income Sources *

Employment Public Assistance Social Security Unemployment Compensation Veterans Benefits None Other

Please type other income source here *

Currently Employed

Yes No

Does your father have a bachelor’s degree? *

Yes No

Does your mother have a bachelor’s degree? *

Yes No

Your current education status: *

In high school High school dropout High school/GED graduate Enrolled in GED program Enrolled in college/tech school Potential college transfer student College/tech school dropout College/tech school graduate

Grade

School

Highest grade completed

Year

Where

Degree

Services Requested

Admissions College Transfer Financial Aid Career Guidance GED Referral GED Practice Test Financial Literacy

Are you currently participating in an Upward Bound, Talent Search or Student Support Services program?

Yes No

Name of MEOC counselor who will assist you: *

Signature certifies that the above information is true and complete. I hereby authorize the Maryland Educational Opportunity Center to release and receive information, including education records, to assist me with my educational planning.

Client name

First Name Last Name

If you have trouble signing below, please type your name above and check the box below.

By checking this box and typing my name above, I am electronically signing my application.

CLIENT

Clear

Parent Name

First Name Last Name

If you have trouble signing below, please type your name above and check the box below.

By checking this box and typing my name above, I am electronically signing my application.

PARENT

Clear

MEOC Confidential Client Intake Application