Delta State University-Cleveland-EOC-Application Form

  • APPLICATION FOR SERVICES

  • DEOC is a federally funded TRIO program designed to assist adults in accessing postsecondary education. DEOC is funded entirely by the United States Department of Education. All DEOC services are free. Please complete the information requested.

    The information contained in this application is confidential and will not be released without your permission.

    • Applicant Information 
    • Date of Birth*
       - -
    • Are you under the age of 18?
    • Mailing address same as physical address.
    • Please check the box for the best contact number to reach you.*
    • Best times:
    • May we send text messages to your mobile number?*
    • Gender:*
    • Race:*
    • Are you a U.S. citizen?*
    • Are you a citizen of the Freely Associated States, including the Federated States of Micronesia and the republics of Palau and the Marshall Islands?
    • Are you an eligible non-citizen?
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    • Do you have a disability?*
    • Are you a Veteran?*
    • If no, are you on active duty?
    • Is your spouse active duty?
    • Do you have a parent/legal guardian who is active duty?
    • Are you a foster child?*
    • Are you homeless?*
    • Military Connected (Check any that apply)
    • Dependency Status and Income: (Please check all that apply to you)
    • Did you check ANY of the Dependency Status boxes above?

    • Independent - Student (and Spouse) Taxable Income

      Dependent - Parent(s) Taxable Income

    • Income source*

    • Independent - Student (and Spouse) Taxable Income

      Dependent - Parent(s) Taxable Income

      Income Source

    • EDUCATIONAL INFORMATION: 
    • Are you currently in high school?*
    • List of Schools:
    • Have you earned a GED or high school equivalent?
    • If no, are you currently in an ABE/GED program?
    • Are you currently enrolled in a postsecondary institution, including junior college, university, or technical school?*
    • If no, have you ever attended college?*
    • Did you graduate?
    • Do you have existing student loans?*
    • Have you participated in any of the following programs SINCE SEPTEMBER 1? (Check all that apply)
    • Have you ever received services from an EOC Project before?
    • Are you currently being served by another TRIO program?*
    • Did either of your parents, biological or adoptive only, complete a Bachelor (4-year) Degree?*

    • If one parent is/was absent from the home please answer only as it relates to the parent you live with.

    • Rows
    • If 18 or older, are you currently unemployed?
    • FUTURE GOALS: 
    • TELL US WHAT YOU NEED: Please check all that apply.*
    • How did you hear about DEOC?*

    • Certification of Application and Information Release


      I/We certify that the information provided on the application is true and correct to the best of my/our knowledge;

      I/We further understand that the completion of this application does not guarantee acceptance into the Delta Educational Opportunity Center (DEOC) program.

      I/We authorize the use of my image and name in DEOC publications, editorials, advertisements, and media releases to the DEOC program and its
      affiliated organizations;

      I/We understand that if I need accommodation for a disability to participate in DEOC, or any of its scheduled activities, I/we must contact the Director of the Delta Educational Opportunity Center at 662.846.4337 at least 10 working days prior to the activity.


      I/We will make every effort to provide DEOC with any requested documentation needed to evaluate/track/report academic progress. Student information is confidential and protected by the Family Educational Rights & Privacy Act (FERPA). We cannot release or obtain certain information without your written permission.

      I/We authorize DEOC to request, receive, and release any academic and financial secondary and/or postsecondary information to assist with services needed.


      I/We further authorize DEOC to communicate verbally or otherwise with campus staff and faculty and/or off-campus professionals on my behalf to assist
      with services needed.

      My/Our consent will remain in effect until I/we revoke this authorization, in writing, with the DEOC office.

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    • If 󠄀󠄀under 󠄀󠄀18, 󠄀󠄀a 󠄀󠄀parent’s 󠄀󠄀or 󠄀󠄀guardian’s 󠄀󠄀signature 󠄀󠄀is 󠄀󠄀also required

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