Marshall University-Heart Of Appalachia-EOC-2025 Application Form

Name:*

First NameLast Name

Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone (Cell):

(999)999-9999

Phone (Alternative):

(999)999-9999

E-mail Address:*

example@example.com

Date of Birth: *

mm-dd-yyyy

Did either of your parents receive a 4-year college degree (bachelor’s degree)?*

YesNo

Including yourself, how many people live in your household?*

Did you have a job last year?

YesNo

If yes, what was your total taxable income for the last year? (Please note:
Taxable income is the amount of income you actually paid taxes on, NOT your gross income. You may need to check your income tax form for this amount.)

If you know your taxable income for last year, please enter amount here:

If exact amount is not available, please indicate the range where your taxable income falls:

Please print and sign your name to verify that the information provided above is correct.

Name:

First NameLast Name

Sign Name:

Date:

mm-dd-yyyy

Are you currently in the*

Race/Ethnicity:*

Gender:*

FemaleMale

Are you a permanent resident of the United States, or can you provide documentation from the U.S. Immigration and Naturalization Service of your intent to become a permanent resident?*

YesNo

Are you currently employed?

YesNo

What is your marital status?

SingleWidowDivorcedLegally Separated

Married (Maiden Name?)

Have you, a parent, or spouse currently or previously been in the military?

YesNo

If yes, please explain?

Did you graduate high school or receive your GED ?*

YesNo

Are you currently enrolled in a GED program or class?

YesNoN/A

If no, what was the last grade that you completed?

Are you currently in*

High School2-year College Program4-year College ProgramN/A

Do you have an associate’s (two-year) degree?

YesNo

Do you have a bachelor’s (four-year) degree?*

YesNo

If you are in college, what college are you attending?

If you stopped attending college and have yet to complete your degree, please list the name of the college you attended and the last time you attended.

Name of College

Last Date Attended

mm-dd-yyyy

What kind of assistance do you need to continue or begin your post-secondary education? (Check all that apply)*

What types of school are you interested in attending?*

2-year4-yearTrade School

What major or career are you interested in pursuing?

When would you like to start school? ?

FallSpringSummer

What Year?

Have you worked with the Heart of Appalachia EOC Program before?

YesNo

If you answered yes, whom did you work with?

Patty MooreRoxanne Smith

How did you learn about the Heart of Appalachia EOC?

I hereby authorize any school, college, or university to release any academic and financial aid information from my files requested by the Heart of Appalachia Educational Opportunity Center (HAEOC). I hereby authorize HAEOC to release academic and financial aid information to assist in my education. I hereby authorize governmental agencies to release to HAEOC the financial documentation necessary to enable my participation in the program.

Name:

First NameLast Name

Signature:*

Date:

mm-dd-yyyy

Heart of Appalachia Educational Opportunity Centers