Chicago State University-Project Success-EOC-Data Intake Form

Project SUCCESS/EDUCATIONAL OPPORTUNITY CENTER (EOC)/TRIO
9601 S. COTTAGE GROVE AVENUE, CHICAGO, IL 60628
OFFICE (773) 995-5215 FAX (773) 734-6587

Date

MonthDayYear
mm-dd-yyyy
Social Security Number
999-99-9999
Name

First NameLast Name
Home Phone
(999)999-9999
Alternative Phone
(999)999-9999
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age
Birth Date

MonthDayYear
mm-dd-yyyy
Email Address
example@example.com
Emergency Contact
Name

First NameLast Name
Relationship
Phone
(999)999-9999
Gender
U.S. Citizen
If you are a Permanent Resident, please attach a copy of your alien registration card

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Cancelof

Military Connection

Rows	Yes	No
Veteran?
Active Duty Military?
Spouse of Active Duty Military?
Child of Active Duty Military?

By signing below, I certify the following:
1. The above information is complete and accurate to the best of my knowledge.
2. Project SUCCESS/Educational Opportunity Center at Chicago State University may use my image for promotional activities.
3. I authorize the release of any academic and/or financial information requested by Project SUCCESS/Educational Opportunity Center at Chicago State University.
4. I agree to furnish Project SUCCESS/Educational Opportunity Center at Chicago State University additional information as requested.
Signature

Clear
Date

MonthDayYear
mm-dd-yyyy