Pima Community College-VUB-Application Form

Application
- Today's Date*
  
  MonthDayYear
  mm-dd-yyyy
- Date of Birth*
  
  MonthDayYear
  mm-dd-yyyy
- Social Security Number*
  999-99-9999
- Name*
  
  First NameMILast Name
- Mailing Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Home Phone*
  (999)999-9999
- Cell Phone*
  (999)999-9999
- Email Address*
  example@example.com
- Gender*
  
  MaleFemale
- Employment Status*
  
  Full-timePart-timeUnemployed
- Ethnicity (check all that apply)*
  
  American Indian/Alaskan NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Pacific IslanderWhite
- 1) What is your highest level of education?*
  
  HS DropoutHS GraduateGED RecipientHS Graduate with Some CollegeGED Recipient with Some CollegeGraduated College with a CertficateAssociate’s DegreeBachelor’s DegreeGraduate Degree
- 2) Years out of school (HS or College)?*
  
  5 or fewer5 or more
- 3) What is your current educational goal?*
  
  HS Diploma/GED CertficateCertficateAssociate’sTransferBachelor’sGraduate
- 4) What majors/fields are you interested in?*
- 5) What career(s) are you interested in?*
- 6) What school are you planning to attend?*
  
  Cochise CCPima CCYavapai CollegeASUGCUNAUUAOther
- 7) What academic subject areas do you think you need help with? (Check all that apply)*
  
  MathEnglish/WritngScienceForeign LanguageOther
- If a Foreign Language, which one?*
- 8) Which of the following do you need to meet your career/educational goals? (Check all that apply)*
  
  GED Info.GED Test PreparationCollege Admissions Info.Accuplacer Test PreparationAcademic AdvisingStudy Skills & Test Taking SkillsAcademic TutoringAssistance Applying for College/UniversityFinancial Aid Info.Assistance Applying for Financial Aid Info.Scholarship Info.VA Education Benefits/GI Bill Info.Financial Literacy Info.Career Certificate Info.Career Info.Employment SkillsEmployment AssistanceComputer/Software SkillsOther
- 9) Are you currently receiving services from another federally funded college preparatory program?*
  
  YesNo
- If yes, which one(s)?*
- 10) Do you have a documented disability?*
  
  YesNo
- Please note that you must submit the following required documents:
  - DD Form 214 with discharge status (Honorable or General)
  - Proof of Income (Income Tax Form or Affidavit)
  Lawful Presence:
- Are you a U.S. Citizen?*
  
  YesNo
- Please provide a copy of your DD Form 214*
  
  Cancelof
- OR
- Are you a Lawful Permanent Resident?*
  
  YesNo
- If Yes, please provide a copy of your Permanent Resident Card*
  
  Cancelof
- Permanent Resident Card #*
- First‐Generation College Student
- Did your mother/legal guardian graduate from a college or university with a 4‐year degree?*
  
  YesNo
- Did your father/legal guardian graduate from a college or university with a 4‐year degree?*
  
  YesNo
- Income Affidavit
- Number of people living in your household (including yourself)*
- What was your TAXABLE* income for the most recent year?*
  *Please note that taxable income is less than adjusted income and listed on the 2nd page of most tax forms.Example: See 1040 line #43, 1040A line #27 and 1040EZ Line #6.
- I certify that all the information on this form is true and complete to the best of my knowledge. I authorize the Veterans Upward Bound Program (VUB) housed at Pima Community College to obtain and review any academic, financial, disability or demographic information or documentation from staff and college instructors needed for the purpose of data collection and demographic reporting, or progress monitoring, both at the time of my application and throughout my participation in the program. I am also aware that the personal information that is provided to the VUB Program will be protected under the Family Education Rights Act of 1974.
  
  If accepted into the program, I understand that I am held accountable and must comply with all aspects of TRiO VUB.
- Signature*
  
  Clear
- Date*
  
  MonthDayYear
  mm-dd-yyyy
- The Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. §1232g, are federal and state laws providing for the review and disclosure of student educational records. Veterans Upward Bound (VUB) TRIO program will not permit access to or the release of personally identifiable information contained in student educational records to any party without the written consent of the student, except as authorized by FERPA.
- Name*
  
  First NameLast Name
- 1. Rate your knowledge with regard to the admissions process*
  
  0 - None12 - A Little345 - Some678 - A Lot910 - Know Everything
- Do you know what the admission requirements are at the school you plan to attend?*
  
  YesNo
- Did you know the admission requirements differ from school to school?*
  
  YesNo
- Do you know how to obtain your military transcript?*
  
  YesNo
- Would you like more information/assistance with the Admission Process?*
  
  YesNo
- 2. Rate your knowledge of the financial obligations and opportunities regarding a college program*
  
  0 - None12 - A Little345 - Some678 - A Lot910 - Know Everything
- Are you familiar with FAFSA, and why you need to complete this application?*
  
  YesNo
- Have you compared the various types of VA Education Benefits?*
  
  YesNo
- Do you understand paying with “first available funds”? *
  
  YesNo
- Would you like more information/assistance with Financial Aid?*
  
  YesNo
- 3. Rate your knowledge with regard to the academic requirements for school*
  
  0 - None12 - A Little345 - Some678 - A Lot910 - Know Everything
- Are you familiar with the SQ3R reading/study system?*
  
  YesNo
- Do you have a designated time and place to study?*
  
  YesNo
- Would you like more information/assistance to prepare academically for school?*
  
  YesNo
- Do you need to brush up on your reading, writing or math skills?*
  
  YesNo
- If so, which ones?*
  
  ReadingWritingMath
- Please tell us about your educational plans and future career aspirations:*
- Signature*
  
  Clear
- Date*
  
  MonthDayYear
  mm-dd-yyyy
- TRiO Veterans Upward Bound is funded under a grant from the U.S. Department of Education, Office of Postsecondary Education