Fresno City College-SSS 2-Application Form

Fresno City College | TRiO CTE-STEM Application

Section 1: Student Information
SECTION 1: STUDENT INFORMATION
Name*

First NameMiddle NameLast Name
Student ID
Social Security Number
999-99-9999
Birthdate

MonthDayYear
mm-dd-yyyy
Sex

MaleFemale
Home Phone
(999)999-9999
Cell Phone
(999)999-9999
College Email*
example@example.com
Personal Email
example@example.com
Mailing Address

Street Address

Apt #

CityState

Zip Code
Ethnicity

American Indian or Alaskan NativeAsianBlack or African AmericanHispanic/LatinoWhiteNative Hawaiian or other Pacific Islander
Primary Language
Where is your birthplace?
Are you a US Citizen?

YesNo
If NO, please check your status below and provide a copy of your INS card

Permanent ResidentNonresident Alien
Registration Card documentation

Cancelof
Are you a current or former Foster Youth?

YesNo
First Generation

What is the highest level of school your parents or guardians have completed?

	Parent/Guardian 1	Parent/Guardian 2
Non Applicable
No schooling completed
Elementary school to 6th grade
Middle school 7th & 8th grade
Some high school, no diploma
High school graduate, diploma or the equivalent (for example: GED)
Some college credit, no degree
Trade/technical/vocational training
Associate degree
Bachelor’s degree
Master’s degree
Professional degree
Doctorate degree

Did your parents/guardians graduate from a University and earn a Bachelor's Degree? For Example: Your parents graduated from Fresno State University.

YesNo
Disabled
Do you have a disability?

YesNo
If yes, please briefly describe
Are you currently receiving services from DSP&S?

YesNo

Section 3: Income Information and Documentation
SECTION 3: INCOME INFORMATION AND DOCUMENTATION
Did you file a Free Application for Federal Student Aid (FAFSA) for this 23-24 academic year?

YesNo
Please provide a copy of your tax return with this application (if 24 years or older) or your parents/guardian tax return from the most recent tax year 2019 or 2018 federal 1040 form (1040 EZ or 1040A form). If you or your parents/guardian do not file taxes please provide proof of all other income or assistance when submitting this application.

Cancelof
If you did not file taxes and/or unable to provide tax returns or proof of income, please write a self-reported statement or your income source and amount you receive on a monthly basis.
Signature that self reported income is true and correct

Clear
Total number of people living in your household, including yourself, parents, siblings, or other dependent in your family *
Are you Low Income (See the Low Income Level table below)*

YesNo
Thank you for applying to the TRIO CTE-STEM Program. Personal information collected is for reporting requirements and is confidential. Any incorrect information given on this application will affect your opportunity to receive services from TRIO CTE-STEM. Your signature gives TRIO CTE-STEM permission to access your financial and academic records at Fresno City College or any other educational institutions you will attend and to consult with faculty and staff at Fresno City College regarding your academic status.

If approved, I agree to maintain a minimum of two counseling appointments and one TRIO CTE-STEM event each semester.
Signature*

Clear
Date Signed*

MonthDayYear
mm-dd-yyyy
Fresno City College Student Support Services TRIO CTE-STEM program does not discriminate on the basis of race, color, national origin, religion, sex, age,or disability in any of its policies, procedures, or practices.

This SSSP TRIO STEM program is full funded by the U.S. Department of Education

Fresno City College | TRiO CTE-STEM Application