• Fayetteville State University

    Educational Opportunity Centers
    1200 Murchison Road

    Fayetteville, North Carolina 28301

    (910) 672-1171 * Fax (910) 672-1207 * eoc@uncfsu.edu

    • Applicant Information 

    • Applicant Information

    • Date of Birth*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Gender:*
    • Veteran?*
    • Active Duty?*
    • Spouse of Active Duty Military?*
    • Child of Active Duty Military?*
    • What is the Primary language spoken in the home?*

    • Disability Status:*
    • Citizen Status:*

    • Ethnicity*

    • Current Education Level:*
    • Needs Assessment 
    • Needs Assessment
      Rows
    • Needs Assessment -Please check your current needs
      Rows
    • I am currently a participant in the following:*

    • I am currently a participant in the following program(s):*
    • Date*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Education/Career Goals 

    • Education/Career Goals

    • First Generation Status 

    • First Generation Status

      First Generation Student

    • Has student’s mother received a 4-year degree from a college/university?*
    • Has student’s father received a 4-year degree from a college/university?*
    • Income Verification 

    • Income Verification

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    • Please check all that apply to you:

    • If none of the above apply to you, please provide your parents income and signature.

      If any of the above apply to you, please provide your own taxable income from last year.

      *Taxable Income*: This information is located on tax forms (1040-line11b) Family Income

    • Public Assistance you or your household receives:*

    • ALL INFORMATION RECEIVED WILL BE KEPT CONFIDENTIAL IN COMPLIANCE WITH THE FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT.

    • Release Forms 

    • I attest that the taxable income provided above is accurate to the best of my knowledge.

    • Date
       - -
      2 digit month, 2 digit day, 4 digit year

    • School Records

      I grant Educational Opportunity Centers (EOC) Program permission to obtain academic records, college admissions enrollment, and financial aid information that is necessary to assist in achieving my education goals.

      Media Release

      Periodically, students participating in the EOC program events may be photographed, filmed, or interviewed.
      I grant permission for EOC staff to use my photographs, film or interviews that may be used to promote or publicize the program events or demonstrate how federal funds are utilized to assist students. 

    • I understand that the above information will be kept confidential and used solely in support of my educational and career goals.
      All the information provided is true and complete to the best of my knowledge.

    • Date*
       - -
      2 digit month, 2 digit day, 4 digit year
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