Northwest State Community College-SSS-Application Form

TRIO - STUDENT SUPPORT SERVICES APPLICATION
Per the Family Educational Rights and Privacy Act (FERPA), information in this application is confidential – we will protect your sensitive personal data. Print Clearly. Incomplete applications may be returned to you or rejected.

Applicant Information
Full Name:*

First NameMiddle NameLast Name
Preferred Name:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:*
(999)999-9999
NSCC ID#:*
N00-
Date of Birth:*

MonthDayYear
mm-dd-yyyy
NSCC Email address:*
example@example.com
In accordance with federal regulations, a student must meet one of the following criteria to be eligible for program services:
Are you a first generation college student (neither parent has a Bachelor's degree)

YESNO
Do you have a documented disability?

YESNO
If yes, have you met with Accessibility Services at NSCC?

YESNO
Do you have limited income?

YESNO

Academic Information
Major:*
Academic Advisor Name:
High School GPA (if less than 3 years after graduation):
What is your expected year of graduation from NSCC?*
Are you*

Full timePart time
What is your current NSCC academic status?

Good StandingSuspensionProbation

Signature
Please sign, date and return this form. If you are considered a dependent, as defined by Free Application for Federal Student Aid (FAFSA), you must have your parent/guardian sign and date this form.
Printed student name:

First NameLast Name
Student Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
Print parent/guardian name (if claimed as dependent):

First NameLast Name
Parent or Guardian Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
Completed applications may be mailed, hand-delivered, faxed/scanned or emailed.

Return to:

TRIO-Student Support Services
22-600 St. Rt. 34
Archbold, OH 43502

Email: triosss@northweststate.edu
(Please indicate “SSS Application-Your Name” in the subject line)

Phone: 419-267-1339
Fax: 419-267-5657
Note: Applying for this program is a commitment and we expect you to be an active participant while you are a student at Northwest State Community College.

If you are admitted to NSCC TRIO Student Support Services, we will require the following commitment from you:
- Meet with my Success Coach at least twice a semester.
- Participate in tutoring sessions as needed
- Participate in financial aid and career development workshops and events.
- Set goals with my Success Coach that lead to my planned graduation.
- Work with my Success Coach to assist with transfering to a four year college after graduation, if a bachelors degree is desired
How did you learn about NSCC TRIO Student Support Services? Please select what applies:

NSCC Staff/FacultyEmailMailing/FlyerNSCC WebsiteAnother TRIO StudentOther
If NSCC Staff/Faculty, who?

TRIO - STUDENT SUPPORT SERVICES APPLICATION