Fayetteville State University-VSSS-Application Form

Fayetteville State University TRIO Student Support Services Veterans (SSSV)
TRIO STUDENT SUPPORT SERVICES VETERANS

TRIO Student Support Services is a federally funded program that provides academic support services to a student meeting the grant guidelines. To be eligible for the program, you will need to demonstrate that you are a military veteran, have an academic need and will provide the following: your taxable income and DD-214. All information provided will be held confidential and used for the TRIO SSS program purposes only.

ALL INFORMATION REQUESTED MUST BE COMPLETED FOR THE APPLICATION TO BE CONSIDERED.
- Full Name*
  
  First NameLast Name
- FSU Banner ID:*
- Date of Birth: *
  
  MonthDayYear
  Date
- Phone Number: *
  (999)999-9999
- FSU Email: *
  example@example.com
- Gender:*
  
  MaleFemale
- Ethnicity/Race:*
  
  Black/African AmericanHispanic/LatinoWhiteAsianNative AmericanPacific IslanderOther
- U.S. Citizen or Permanent Resident:*
  
  YesNo
- Current Academic Level:*
  
  FreshmanSophomoreJuniorSenior
- Major/Program of Study:*
- Expected College Graduation Date? *
- Are you a transfer student?*
  
  YesNo
- Are you currently enrolled full-time at FSU?*
  
  YesNo
- Military Service
- Component:*
  
  Active DutyNational GuardReserve
- Branch of Service*
  
  ArmyNavyAir ForceMarinesCoast GuardSpace Force
- Are you a military Veteran with a DD-214?*
  
  YesNo
- Years of Service:*
- Rank*
- Are you using VA Benefits?*
  
  YesNoPending
- Type of Benefit*
  
  Post-9/11 GI BillMontgomery GI BillVocational Rehab (Ch. 31)Other
- INCOME VERIFICATION (Family taxable income ≤150% of poverty level)
  
  Please complete the information below, which verifies your family income for the last year.*Taxable Income*: This information can be found on Line 11b of your 1040 form. DO NOT USE YOUR ADJUSTED GROSS INCOME*
  
  Family Income: What is your family's *Taxable Income for last year? (not to include non-taxable income such as SSI, VA Disability, Child Support, TANF, etc.) Federal TRIO Programs Current-Year Low-Income Levels | U.S. Department of Education
- What is your income Level?*
  
  $0 to $23,475$23,476 to $31,725$31,726 to $39,975$39,976 to $48,225$48.226 to $56,475$56,476 to $64,725$64,726 to $72,975$72,976 to $81,225$81,226 or higher
- How many individuals currently living in the household (including myself)?*
- FIRST GENERATION
- Did either natural or adoptive parent graduate with a 4-year degree or higher prior to your 18th birthday?*
  
  YesNo
- Prior to age 18, did regularly reside with the natural or adoptive parent graduate with a 4-year degree or higher?
  
  YesNo
- DISABILITY ☐ Are you registered with the Office of Disability Services?*
  
  YesNo
- Support Services Needed*
  
  Academic TutoringStudy Skills / Time ManagementCareer & Professional DevelopmentFinancial & Economic LiteracyGraduate School PreparationMental Health or Wellness SupportMentorship / Peer ConnectionsAcademic AdvisingOther
- Briefly describe your educational and career goals: *
- I certify that the information provided above is accurate to the best of my knowledge. I authorize the release of academic, financial, and enrollment information to the FSU TRIO SSS Veterans Program for eligibility verification and program evaluation purposes.
- Signature:*
  
  Clear
- Date*
  
  MonthDayYear
  Date
- Fayetteville State University
  
  Student Support Services
  
  Student Contract
  
  I understand that the Student Support Services Program is a federally funded program, and that my selection to participate in the program is based on my meeting the federal eligibility criteria.
  
  · As a SSS Participant I agree...
  - To actively participate in the Student Support Services Program, which is designed to provide the following services: tutoring, counseling, academic support workshops, information regarding financial literacy, and graduate school preparation which will help me, achieve success during my tenure here at this institution.
  - To meet with my assigned SSS Advisor at least 1 time a semester.
  - To actively participate in SSS Workshops; attend at least 2 workshops each semester which will help me achieve my academic goals.
  - To arrive on time to all scheduled tutoring sessions with prepared class assignments, textbooks, and notes for each tutoring session.
  - To meet with my advisor during mid-term advisement to review my academic status.
- Media Permission: I give TRIO SSS-V permission to include me in photographs, films, publications, or interviews as they pertain to TRIO Student Support Services Veterans and I understand that such pictures, films, or interviews may be used to promote or publicize TRIO Student Support Services VETERAN events and/or program."
  
  YesNo
- I have read the above statements and understand that I will be put under a probationary period upon my initial intake into the program which may exceed two semesters of my enrollment at FSU.
- I will adhere to the contract by signing below: Student Signature*
  
  Clear
- Date*
  
  MonthDayYear
  Date

Fayetteville State University TRIO Student Support Services Veterans (SSSV)