University Of Wisconsin-Parkside-EOC-Application Form

Name:*

First NameLast Name

Date of birth:*

mm-dd-yyyy

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County:*

Phone Number:*

(999)999-9999

Email:*

example@example.com

What areas are you interested in learning more about? (check all that apply)*

How did you hear of us?*

Race (check all that apply):*

Ethnicity: Are you Hispanic/Latino?*

YesNo

Gender:*

MaleFemale

Is English your first language?*

YesNo

If no what is your preferred language?

If no do you need ESL classes?

YesNo

Do you have a disability?*

YesNoLearningPhysical

Are you currently incarcerated?*

YesNo

If yes what is your release date?

mm-dd-yyyy

Are you in active service?*

YesNo

Are you a veteran?*

YesNo

Are you the spouse of an active service member?*

YesNo

Are you the spouse of a veteran?*

YesNo

What is your residency status:*

Citizen of the USPermanent ResidentPermanent Resident of Trust Territory of Pac. Is.In US with the intention of permanent residency

Social security number:

999-99-9999

Do either of your parents have a 4-year college degree?*

YesNo

How many people are in your family?*

Employment status:*

Employed full timeEmployed part timeUnemployed

Income you received last year:*

Do you receive any of these benefits?

I am interested in going to college*

YesNo

Educational Goal*

Certificate2-year Associate's degree4-year Bachelor's degree

Highest level of schooling completed:*

If did not graduate high school, highest grade completed:

Are you currently enrolled in school?*

YesNo

If yes, where?

I certify that the information provided here is accurate. I understand that it can be used for statistical and tracking purpose only. I authorize UWP EOC to obtain records relevant to my educational planning and financial aid eligibility, and to release information as required by law to the US Department of Education. EOC has my permission to contact me to collect enrollment information and to provide further services. I agree to abide by the rules of the UWP Educational Opportunity Center.

I certify that the information provided here is accurate*

I certify that the information provided here is accurate. I understand that it can be used for statistical and tracking purpose only. I authorize UWP EOC to obtain records relevant to my educational planning and financial aid eligibility, and to release information as required by law to the US Department of Education. EOC has my permission to contact me to collect enrollment information and to provide further services. I agree to abide by the rules of the UWP Educational Opportunity Center.

Signature:*

Date:*

mm-dd-yyyy

Educational Opportunity Center Application

Interest

Demographic information

Military service

Residency Status

First generation status

Income

Education Status

Consent/contract