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

Applicant Information
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

MaleFemaleNo ResponseOther
U.S. Citizen*

YesNo
If you are a Permanent Resident, please attach a copy of your alien registration card

Browse Files

Cancelof

Military Connection

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

Disability (This information is voluntary)

YesNo
Type
Ethnic Background

African AmericanAsian AmericanHispanic AmericanNative AmericanWhiteOtherNo Response

Certification
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