Pensacola State College-EOC-2023 Application Form

Application Form
- Name
  
  First NameMiddle Initial (MI)Last Name
- Mailing Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- County
- Phone
  (999)999-9999
- Would you like to receive text messages from the EOC?
- Email
  example@example.com
- Birth Date
  
  MonthDayYear
  Date
- Age
- Referred By
- Gender
- Marital Status
- Military Status
- Do you support a child/dependent?
- Are you receiving services from another TRIO program?
- If YES, from which TRIO program are you currently receiving services?
- Is English your second language?
- Citizenship Status:
- Alien requisition number
- SSN
  999-99-9999
- Ethnicity
- Source of taxable income (line 15 from your 1040) Note: if under the age of 24 and dependent, identify parent's source of income, please check all that apply
  
  Other
- Required to file income tax returns?
- Family Size
- Taxable Income, Line 15 of Form 1040
- Current-Year Low-Income Levels?
  
  https://www.ed.gov/about/ed-offices/ope/trio/federal-trio-programs-current-year-low-income-levels
  
  *IMPORTANT NOTE: TRIO/EOC is REQUIRED to have your parent's signature to verify their taxable income above only if you're considered a "dependent" according to FAFSA guidelines. In addition, you may need to provide supporting documents if you're "independent". Please consult with your TRIO/EOC Academic Counselor if you have any questions.
  
  *Dependent=A student who does not meet any of the criteria for an independent student. An independent student is one of the following: at least 24 years old, married, a graduate or professional student, a veteran, a member of the armed forces, an orphan, a ward of the court, someone with legal dependents other than a spouse, an emancipated minor or someone who is homeless or at risk of becoming homeless.
- Parent Full Name
  
  First NameLast Name
- Parent Signature
- Do you have a physical/learning disability which may require special accommodations for you to succeed academically and you would like to voluntarily give information for purposes of coordinating with The Student Resource Center for American Disabilities Act (ADA) Services?
- Does your supportive parent(s) have a four-year degree?
- Educational Status:
- Earned
- What EOC services are you interested in receiving today?
- I, the client, certify the above information is accurate and complete to the best of my knowledge. The TRIO/EOC staff have my permission to receive copies of my educational records and other material necessary for participation in their services. I further understand all my records will be kept in confidence and in accord with the Privacy Act of 1984. Permission is granted to send enrollment and financial aid information to TRIO/EOC of Pensacola State College 1000 College Blvd., Building 6, Room 610, Pensacola, FL 32504.
- Client Signature
- I am unable to fill out the signature box above and would prefer to only type my name below. By checking this box and typing my name below, I agree that I am electronically signing my application.
- Name
  
  First NameLast Name
- Pensacola State College does not discriminate against any person on the basis of race, ethnicity, national origin, color, gender/sex, age, religion, marital status, pregnancy, disability, sexual orientation, gender identity, or genetic information in its educational programs, activities, or employment. For inquiries regarding Title IX and the College's discrimination policies, contact the Executive Director of Institutional Equity and Student Conduct at (850) 484-1759, Pensacola State College, 1000 College Blvd., Pensacola, Florida 32504.
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