Pitt Community College-EOC-2022 Application Form

Name:*

First NameMiddle InitialLast Name

Social Security Number:

999-99-9999

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone: Home

(999)999-9999

Phone: Cell

(999)999-9999

Email:*

example@example.com

Date of Birth:

mm-dd-yyyy

Gender

FemaleMale

Ethnicity: Are you Hispanic or Latino?

YesNo

Select one of more races.

Marital Status:

SingleMarriedOther

Do you have any children who receive more than half of their support from you?

YesNo

If so, how many?

Do you have dependents (other than your children or spouse) that live with you and receive more than half of their support from you?

YesNo

Number of Dependents:

Family Size:

Dependency Status: If you are a dependent student (you live with your parent and they are responsible for you) please provide the following:

Parent's Name:

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Did Either Parent Complete a 4 Year Degree:

YesNo

Parents Taxable Income:

Are you a U.S. Citizen?

YesNo

If no, please list your Eligible non-citizen registration number

A:

*Are you a veteran?

YesNo

Please check the highest grade level you completed:

Please indicate your (& spouse’s) taxable income last year:

$

How did you hear about our Educational Opportunity Center?

Signature and Permission

I give TRiO: Educational Opportunity Center permission to hold and maintain in my case file, college or GED admissions, financial aid, college placement, assessment scores, verification of income, enrollment, class schedules, transcripts or other pertinent information necessary to assure educational attainment and student success, including completing college applications and financial aid applications. The information I have provided on this service application is complete and accurate to the best of my knowledge. I certify as a parent/guardian that the income information is correct:

Student Signature:

Date

mm-dd-yyyy

Parent Signature (if you are a dependent student):

Date

mm-dd-yyyy

The Educational Opportunity Center is funded by a grant from the U.S. Department of Education and is administered by TRiO Educational Opportunity Centers. It is part of the U.S. Department of Education’s TRiO Family Programs.

Main Location: Educational Opportunity Center, 2402-A Reedy Branch Road, Winterville, NC 28590 Phone: (252) 493-7556 Fax: (252) 321-7561 Website: www.pittcc.edu

Partner Locations are in Pitt, Edgecombe and Martin counties.