Florida A & M University-EOC-Application Form

TRIO Educational Opportunity Center

Participant Application 2021-2022

Please complete the application in its entirety. For questions that do not apply click on the N/A option or type it in the box.

Name*

First NameMILast Name

SSN Number*

999-99-9999

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County*

Telephone Number*

(999)999-9999

Phone Type*

Email Address*

example@example.com

Date of Birth*

mm-dd-yyyy

Age*

Gender*

MaleFemaleOther

Race/Ethnicity (check all that apply)*

Are you proficient in the English language?*

YesNo

Are you a U.S. Citizen?*

YesNo

Military Status: Are you a(n)*

Did you/will you file taxes for last year?*

YesNo

If you are under age 24, did your parent(s) files taxes last year?*

YesNoN/A

Household size*

Please indicate your household’s TAXABLE INCOME range for last year*

Did either of your parents, or the parent that you lived with prior to your 18th birthday, receive a 4-year college degree? *

YesNo

Current grade level*

Current Education Level*

High School JuniorHigh School SeniorAdult Learner (enrolled in an Adult Education program)High School Graduate (not enrolled in college/vocational program)Post-secondary Student (enrolled at a community college or vocational school)Post-secondary Student (enrolled at 4-year college/university)Post-secondary Student (that stopped out)High School dropout (not enrolled in an Adult Education program)

Current School (write N/A if not enrolled)*

Are you currently enrolled in an Adult Education Program? *

YesNo

Are you currently enrolled at a postsecondary institution? *

YesNo

Have you ever attended a community college or a university in the past?*

YesNo

If you stopped out of college, what was the last month/year you attend (Type N/A if this does not apply to you)*

What is the name of the school you attended?*

Did you earn a certificate or Associate Degree? *

YesNo

In what type of education or training are you interested?*

GED/Adult EducationVocational/Tech School2-Year College4-Year College/University

Where do you intend to apply?*

What is your intended major?*

How did you hear about us?*

Radio AdPresentationCounselorOther

Would you like to refer a friend or family member for EOC Program services?

YesNo

Friend/Family Name

First NameLast Name

Friend/Family Email

example@example.com

Friend/Family Phone Number

Are you interested in a free online self-paced financial literacy course?

YesNo

I hereby authorize any school, post-secondary institution, continuing education program, or governmental agency to release any academic/financial aid information from my files that are requested by the FAMU Educational Opportunity Center.

I hereby authorize FAMU EOC to release academic and financial aid information along with any other information determined as relevant and necessary to assist with my educational pursuits."

I am not presently served by the Educational Talent Search Program.

I have been given the opportunity to participate in any services offered by EOC. I authorize the use of my image/name with EOC publications, editorials, advertisements, and media releases. I authorize the EOC Program to release academic and financial aid information to assist me with my education. To the best of my knowledge, all information given on this application is correct.

I certify that, to the best of my knowledge, all information given is correct.

Participant's Signature*

Parent's Signature*

How did you hear about us?

Services are provided by the FAMU EOC counselors without regard to race, ethnicity, national original, creed, gender, disability or sexual orientation.

The FAMU Educational Opportunity Center is a Federal TRIO Program funded by the U.S. Department of Education and sponsored by Florida A&M University