Piedmont Community College-Roxboro-EOC-Adult Application Form

EDUCATIONAL OPPORTUNITY CENTER (EOC)
Piedmont Community College/TRIO
1715 College Drive, Roxboro, NC 27573
Telephone: (336) 599-1181

EOC Adult Application Form (19 years and older)

Participant Education Status*

High School Graduate/GEDCollege Transfer (NCE)Adult Learner (NCE)

Participant Status*

New to EOCContinuing EOC Participant

EOC County*

Name*

First NameMILast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County*

Date of Birth*

mm-dd-yyyy

Age*

Gender*

MaleFemale

Home Phone*

(999)999-9999

Mobile Phone*

(999)999-9999

Personal Email*

example@example.com

Citizenship Status*

U.S. CitizenPermanent Resident

Permanent Resident #*

Ethnicity*

EDUCATIONAL ACHIEVEMENT

I have a high school diploma/high school equivalency/GED.*

YesNo

I plan to obtain GED/high school equivalency:

Year of obtaining GED/high school equivalency:*

Name of School*

COLLEGE PLANS

I plan to _____ college/vocation....*

StartRestartContinue

College*

Semester*

FallSpringSummer

Year*

INTENDED COLLEGE MAJOR/COURSE OF STUDY/TRADE*

REQUESTED MATERIALS AND SERVICES (Check all that are applicable)

I need assistance in the following areas:

I’ve already completed:

Military*

I would like to be considered for the EOC Scholarship!*

YesNo

Do either of your parents have a Bachelor’s degree (four-year degree) or higher?*

YesNo

Do either of your parents have an Associate degree (two-year degree) or higher?*

YesNo

Have you been awarded a Pell Grant for college?*

YesNo

What was your family’s taxable income for the previous year?*

What is the number of people living in your household?*

Agreements (Check all that apply)*

I understand that the above information will be held strictly confidential and will be used for statistical and follow up purposes only.I attest that all information provided on this application is true to the best of my knowledge.I grant the Educational Opportunity Center permission to use my name and personal image in all forms of media for lawful purposes.I understand that I (and parents, if necessary) must sign a Hold Harmless form in order to take part in EOC field trips/campus visits.

New Participant Signature*