Eastern New Mexico University-Roswell-EOC-Application Form

College Level

Are you currently enrolled in college or taking college classes(Fall 2022, Spring/Summer 2023)?

Are you in any other TRIO Programs (SSS, TS, UB)?

TRIO Program

Trio Program:

Name

First NameMiddle Initial Last Name

Address

Street Address

Street Address Line 2

CityState

Zip Code

Telephone

(999)999-9999

Email Address

example@example.com

Date of Birth

Date

Age

Social Security Number

999-99-9999

Gender

Are you a U.S. Citizen or Permanent Resident?

Ethnicity

High School Diploma/GED

As of today, what is your level of education:

Date Completed

MM-DD-YYYY

Did you graduate from HS or receive GED/HISET

Other levels of education that may apply:

Which Semester

Currently enrolled in college (circle semester)

Other levels of education(check all that apply):

Have your Father or Mother Completed a Bachelor's Degree?

Parents Education Level: Father, HS Grade/GED

Parents Education Level: Mother, HS Grade/GED

First in Family to Attend College?

Single parent family?

Do you have children and/or are you married?

Family's Taxable Income (Yearly)

$______

Number in Household

College Choices

(For example, ENMUR, NMSU, UNM)

Career/Degree Choice

(For Example, HVAC, Nursing, Education)

Military Status

Does anyone in your household receive the rolling (Other Assistance)/Amount received monthly

Rows	Yes/No?	Amount
Social Security
Child Support
Workers Comp.
TANF
Veterans Benefits
Unemployment Comp.
N/A

Total Amount Received Monthly

$_____

Do you consent to receive text messages from EOC on FAFSA reminders and events?

Has EOC counselor assisted student in the following

Rows	Yes/No?
Client interested in attending College/University
Provided information and/or assisted in filing for FAFSA
Provided an admission form and/or assisted filing application
Student received check list of necessary items to complete FAFSA
Enrolled in a continuing educational program
Provided information for scholarships
Reviewed Financial Literacy Loan Process

Which of the following services would be helpful to you: (select all that apply)

I certify that the information contained in the application is true, complete and correct to the best of my knowledge. I understand that I am giving permission of consent for the Educational Opportunity Center at ENMUR to view my federal taxes, government benefits, student records, enrollment status for tracking purposes and to complete the free application for the Federal Student Aid (FAFSA).

Although disclosure of these items is not required, ENMU-Roswell must report this data in composite form to state and federal agencies. It is the policy of ENMU-Roswell not tot discriminate on the basis of race, creed, sex, color, age, disability, or national origin in its educational programs, activities, or, or employment procedures. Funded by the U.S. Department of Education. Award Number: P066A210130

Student Signature:

Date

mm-dd-yyyy

Parent Signature: (Required if the student is under 18 years old)

Date

mm-dd-yyyy