Pima Community College-VUB-Application Form

Eligibility Information
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.

Affidavit & Signature
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.