Salem State University-SSS-Application Form

Name:*

First NameLast Name

Salem State University ID #:*

Do you have any records under another name?*

YesNo

If yes, under what name:*

First NameLast Name

Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone #:*

(999)999-9999

Email Address:*

example@example.com

Date of Birth:*

mm-dd-yyyy

Please select the gender identity with which you most closely identify:*

MaleFemaleTransgenderGender Variant/Non-Conforming

Marital Status:*

Do you have any dependent children?*

YesNo

How many dependent children do you have?*

Citizenship Status:*

U.S. CitizenPermanent Resident

U.S. Veteran Status:*

VeteranNon-Veteran

Please select the ethnicity background with which you most closely identify:*

Hispanic/LatinoNon-Hispanic/Non-Latino

Please select the racial background with which you most closely identify:*

Is English your native language?*

YesNo

If no, what is your native language?*

Do you have a Bachelor's Degree from another Institution?*

YesNo

Which institution did you receive your Bachelor’s Degree from?*

Are you a transfer student?*

YesNo

If yes, list transfer college/university:*

Has it been five or more years since you last attended college?*

YesNo

Are you a former TRIO Student? (Upward Bound, Talent Search, Student Support Services, Educational Opportunity Center)*

YesNo

If yes, which program and school?*

Program Eligibility (please check all that apply):*

I am a First-Generation College Student (Neither parent/guardian has completed a degree from a four-year college or university)I am a student with a documented disabilityI am considered low-income to the best of my knowledge

How many people live in your household?*

If known, what is your annual household taxable income?

Annual household taxable income: _______________(Taxable income can be found on Federal Tax Form1040EZ: line 6, 1040A: line 27, 1040: line 43)

Have you applied for financial aid at Salem State?*

YesNo

If you checked yes, do you grant TRIO Student Support Services permission to verify financial aid information such as, but not limited to, student aid report (SAR) information and financial award documentation?*

YesNo

Are you registered with Disability Services at Salem State?*

YesNo

If you checked yes, do you grant TRIO Student Support Services permission to confirm your registration with Disability Services?*

YesNo

WAIVER AND INFORMATION RELEASE

I understand that TRIO Student Support Services (SSS) at Salem State University (SSU) will use the information provided on this form to determine my eligibility for program participation, and to assess my academic and/or career planning needs. I am aware that the information provided will be kept confidential and only used for annual reporting purposes, as required by the U.S. Department of Education. I further understand that completion of this application does not constitute acceptance into TRIO SSS. I give permission for TRIO SSS staff to disclose and receive information from appropriate departments, faculty and staff at SSU, concerning my academic performance, financial aid status, progression towards graduation and any other information and records the program considers pertinent, up to four years after my initial participation. In addition, my signature below verifies that the information reported on this application is true and accurate to the best of my knowledge.

The Student Support Services Program may obtain from sources at Salem State all information and documents necessary to successfully provide the services needed by the student and to fulfill Program regulations. These include, but are not limited to, transcripts, grade forms, application materials, financial aid information, and medical reports. The staff of the TRIO Student Support Services may contact Salem State faculty and staff to inquire about my progress or obtain any information necessary to successfully provide the services I may need. Additionally, my signature certifies that the information given in this application is complete and accurate. I understand and acknowledge that making false or fraudulent statements within this application could result in denial of services.

Signature*

Date*

mm-dd-yyyy

PROGRAM APPLICATION