Arkansas Technical University-VUB-Application Form

Program Application

TRiO Veterans Upward Bound at Arkansas Tech University is 100% funded by a Federal Grant from the U.S. Department of Education
We are pleased that you are interested in the Arkansas Tech University Veterans Upward Bound Program. The purpose of this program is to provide eligible men and women who served in the United States Armed Forces an opportunity to acquire the skills and motivation necessary for the pursuit and completion of postsecondary education.

Please complete your application carefully and fully. Your application must be complete to be considered for the program. The information you provide is held confidential in accordance with the Family Educational Rights and Privacy Act (FERPA) regulations.
Please also attach a copy of your DD214 with discharge status and taxable income verification documents such as a signed copy of IRS 1040, 1040A, or 1040EZ, if applicable, or your state nontaxable income based on the previous calendar year.

Contact Person: Must be a spouse, family, or close relative or family friend.
Name:

First NameLast Name
Relationship:
Address:

Address:

Street Address Line 2

City:State:

Zip:
Phone:
(999)999-9999
E-mail Address:
example@example.com
Initial. College Photo and Videotape Policy as stated in MARCOMM policies, applies to VUB TRIO events. Photographs might include students participating in VUB TRIO events and might be used in college publications and for publicity, including their website and other social network sites. Your email address will be entered to receive updated VUB TRIO blog postings.
Initial. Family Education Rights and Privacy Act. In accordance with the Privacy Act of 1974 (Public law No. 93-579, 5 U.S.C. 552A), you are hereby notified that the Department of Education is authorized to college information to implement the veterans Upward Bound program under Title IV of the Higher Education Act of 1965, as amended (Pub. Law 102-325, sec. 402C). In accordance with this authority, the Department receives and maintains personal information o participants in the Veterans Upward Bound Program. The principle purpose for collecting the information is to administer the program, including tracking and evaluating participants' academic progress. providing the information on this form, including a social security number (SSN) is voluntary; failure to disclose a SSN will not result in denial of any right, benefit or privilege to which the participant is entitled. The information that is collected on this form will be retained in the program files and may be release to other department officials in the performance of official duties.
Initial. Release of Information. With my signature, I grant permission to the staff of Arkansas Tech and specifically the TRIO Veterans Upward Bound Program, to access my high school record and postsecondary records including academic, enrollment, and student aid award information from the college(s)/university(s) I have attended or will attend. I understand that all information will be kept confidential and that records will be used for documenting eligibility for the program and for reporting purposes. Information concerning attendance and progress in program may be shared with authorized third party outside Arkansas Tech and VUB TRIO Program.

Participant Acceptance Agreement
I certify the entirety of the information provided, including my stated taxable income, is accurate and complete to the best of my knowledge. If I am accepted in the TRIO Veterans Upward Bound program, I agree to actively participe in my own academic success while completing my identified academic goals. I understand that the VUB TRIO Program is offered to a limited number of veterans who qualify each year and that is an opportunity for me to receive free services that will successfully prepare me for a college, a university or technical school education. I understand that as a VUB TRIO Program participant, I am held accountable to read and understand the Arkansas Tech Student Code of Conduct. I agree to adhere to Arkansas Tech and VUB Program policies & procedures including appropriate computer use. I futher understand that should I commit any violation of these policies, I could be withdrawn from the program.
Applicant Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Veteran's Statement
To qualify for services offered through the Veterans Upward Bound Program, you must meet one of the following requirements:

1) Have served for a period of more than 181 days, any part of which occurred after January 31, 1955, and was discharged or released from active duty under conditions other than dishonorable;

or

2) After January 31, 1955, was discharged or released from active duty because of a serviceconnected disability.

or

3) Was a member of a reserve component of the Armed Forces called to active duty for a period of more than 30 days;

or

4) Was a member of a reserve component of the Armed Forces who served active duty in support of a contingency operation on or after September 11, 2001.

My signature below verifies that I meet one of the above statements:
Print Name:

First NameLast Name
SSN:
(last 4)
Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy

Program Application