East Central University-VSSS-Application Form

Date

ECU ID Number

Name*

First NameMiddle InitialLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Contact Phone:

(999)999-9999

Email*

example@example.com

Gender

MaleFemale

Married

YesNo

Date of Birth

Date

US Citizen

YesNo

Veteran

YesNo

Branch of Service

Is your Military service discharge dishonorable?

YesNo

If utilizing VA education benefits, which chapter?

Do you have a service-connected disability?

If no, do you need information about applying for a service-connected disability?

Do you have a service or non-service-connected disability for which you might need accommodations (such as extended time for taking examinations)?

YesNo

Do either of your parents have a 4-year College degree (bachelor’s degree)?

YesNo

As Applicant for ECU's Veteran Student Support Services program, I do hereby verify (to the best of my knowledge) that the taxable income (Tax form 1040line 11b, 1040-SR line 11b, 1040EZ line 6) for the year

was $

and the total number of people in the household is

Ethnic Groups/Race

Are you Latino or Hispanic?

YesNo

Are you a transfer student?

YesNo

From where?

How many credits transfer to ECU?

RELEASE OF INFORMATION AUTHORIZATION
This is to certify that information given to the Veterans Student Support Services staff is true and correct to the best of my knowledge. I give Veterans Student Support Services my permission to receive copies of my educational records and other materials necessary for support and participation in this program.

Signature

Date

East Central University Veterans Student Support Services Intake Application