Palm Beach State College-SSS 1-Application Form

Date

DOB

Date

Gender

Applicant’s Name:

First NameMiddle InitialLast Name

PBSC SID#:

Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home phone

(999)999-9999

Cell phone

(999)999-9999

PBSC Email Address:

example@example.com

How did you learn/hear about TRIO Student Support Services?

Have you participated in TRIO before?

If yes, when and which program.

Campus Location:

I am registered for classes at PBSC.

My attendance will be mostly:

What is the primary language spoken at home?

Other languages spoken:

Did you earn your high school diploma?

Date of GED

Date

What degree are you seeking?

Major

To what college/university do you plan to transfer?

Have you attended college before?

If yes, where and how many credits have you earned?

Institution

Number of Credits

Type of Degree Earned

Tell us about your academic and career goals:

Are you a US Citizen?

If no, are you a permanent resident?

Do you identify yourself as Hispanic/Latino

Please select the race(s) with which you identify: (Check all that apply)

If yes: 1. Do you have a documented disability?

2. Have you signed up with the College’s Center for Student Accessibilty?

First Generation Status: Have either of your natural or adoptive parents received a bachelordegree (4-year college degree)?

If yes, was it your:

1. Have you applied for financial aid?

2. Are you receiving financial aid?

3. At age 18 were you living with:

4. Are you an independent or dependent student?

5. Do your parents claim you as an exemption on the tax return?

6. Do you have dependents to whom you provide care for 50% or more of the time?

Income Verification (please fill out BOTH Responses)1. Family size (including you)

. Taxable Income from last year 1040 Tax Form - Line 15:

a. If you (independent) or parent (dependent) did not file please list wages, salaries, tips, and other non-taxedincome:

Please indicate

Are you 24 years of age or older?

Are you married?

Do you have a dependent child?

Are you a veteran of the U.S. Armed Forces?

Were you a foster child, or are you a ward of the court?

I authorize TRIO SSS to use my name/picture for public recognition as part of the TRIO SSS program. (Initial) TRIO Student Support Services is a program designed to help you graduate. The information provided is confidential and will help
determine eligibility for the TRIO SSS program. Discrimination is prohibited on the basis of race, gender, color, national origin, religion, age, disability, marital or parental status, or sexual orientation. I hereby authorize SSS/TRiO to access, obtain, and share any information pertinent to my participation in the program. This information includes, but is not limited to, medical, financial aid information, standardized test scores, transcripts, disability documentation, transfer information, graduation information, and grade reports. Under penalty of perjury, I certify that I have read this application and that it is accurate and complete to the best of my knowledge

(Applicant’s or Parent/Guardian Signature)

Date

Updated 9/13/2023 TRIO Student Support Services4200 Congress Ave ● Room: SCA-126 ● Lake Worth, FL 33461Phone: (561)868-3392