Western Kentucky University-EOC-2024 Application Form

Name

First NameMiddle InitialLast Name

Social Security Number or WKU ID or SKYCTC ID

Local Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County of residence:

Phone Number:

(999)999-9999

Email Address:

example@example.com

Date of Birth:

Date

Gender:

Sex

Ethnicity: Are you Hispanic/Latino?

If “No”, please select from below:

Is English your first language?

U.S. Citizen?

If Not a US Citizen, eligible non-citizen number

If not a US Citizen, Place of Birth

Please check if you are a (an):

Are you now or have you been:

As of today, are you:

Are you providing more than 1/2 of the support for any children or other dependents (not including a spouse)?

For how many dependents are you providing this support?

Total # in household

What was your taxable income (Please Select One)

Are you or anyone in your household receiving:

Did either parent receive a 4-year degree before you turned 18?

What is your CURRENT educational status? (Choose ONE)

Where?

Year?

What grade were you in when you last attended school?

I Need Information On:

I Need Assistance With:

Other

I grant permission for my name/ photo to be released for advertising purposes.

WKU’s EOC project is a USDE funded project which does not discriminate on the basis of age, color, national origin, sex, handicap, or religion, in admission policies, the administration and implementation of educational policies, employment, or any other activity.

I hereby authorize the exchange of information between the Educational Opportunity Centers (EOC) and other agencies, as necessary to assist me in achieving my educational goals. By signing and dating this application, I certify that, to the best of my knowledge, all information given is correct. By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

Signature

Today's Date

Date

Signature:

WKU Educational Opportunity Centers Application Form