Alamo Colleges District-Northeast Lake View-SSS-Application Form

DEMOGRAPHIC INFORMATION

Name*

First NameMiddle NameLast Name

Banner ID:*

Preferred Name:

Date of Birth:*

mm-dd-yyyy

Gender:

MaleFemale

Primary Phone:*

(999)999-9999

Social Security Number:*

999-99-9999

Current mailing address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Personal Email:*

example@example.com

Student Email:*

example@example.com

Race/Ethnicity:

Eligible students must be a citizen or national of the United States, a permanent resident, or meet the residency requirements for Federal Student financial assistance.

Are you a U.S. Citizen or U.S. National, Permanent Resident, or an individual who meets the residency requirements for Federal Student financial assistance?*

I am a U.S. Citizen.I am not a U.S. Citizen, but I am a Permanent Resident.I am neither a U.S. Citizen or Permanent Resident; however, I meet qualifications to receive federal financial aid.I do not meet the criteria indicated above.

What is your major?*

Are you currently enrolled at Northeast Lakeview College?*

YesNo

Have you earned a college degree or certification?*

YesNo

If yes, please select the type of degree:

Please list the awarding institution(s) for the degree(s) selected above. If you have more than one degree, please the degree type:

Do you have a documented disability? (This question is used to determine program eligibility. Your responses will be kept confidential. Selecting “Yes” will not keep you from being selected for the program. Students who select “No” or “Prefer not to answer” may be admitted using other program eligibility.)*

YesNoPrefer not to answer

If yes, are you registered with the Student Accessibility Services Office (SAS)?

YesNoPrefer not to answer

Are you currently participating in another TRIO program?*

YesNo

If yes, please indicate which program you currently receive services from?

Have you previously received services from a TRIO program?*

YesNo

If yes, please indicate which program you receive services from previously?

PARENT/GUARDIAN EDUCATIONAL INFORMATION

Has your mother received/earned a 4-year college degree?*

YesNo

Has your father received/earned a 4-year college degree?*

YesNo

Has your guardian received/earned a 4-year college degree?*

YesNo

FINANCIAL VERIFICATION INFORMATION

Did you submit a FAFSA?*

YesNo

For the purposes of FAFSA, are you a dependent or independent student?*

Did you have children or other dependents (other than a spouse) who receive more than half of their support from you?*

YesNo

Number of persons, including you, living in your household:*

What is your family’s taxable income from the last calendar year?*

Note: Taxable income can be found on the federal income tax return. On IRS Form 1040, see line 15.

Have your financial circumstances changed due to special or unusual circumstances (i.e., job loss, etc.)?*

YesNo

Please describe the changes you want considered in your application:

If you did not file a federal income tax return for the last calendar year, please list your total income for the last calendar year:

Please check here if you had no taxable income for the last calendar year:

No taxable income for the last calendar year.

EMERGENCY CONTACT

First and Last Name:*

First NameLast Name

Relationship to Student:*

Contact Phone #:*

(999)999-9999

Contact Email:*

example@example.com

STUDENT ACKNOWLEDGEMENT

By signing this application, I attest that all the information on this application is true. Moreover, I authorize the release of my official academic records to the TRIO Student Support Services (SSS) project at Northeast Lakeview College, understanding that the information in these records will be used only to assess the need for TRIO program services, discern educational progress, evaluate the effectiveness of TRIO program activities, and fulfill TRIO program-reporting requirements to the U.S. Department of Education.

Student Signature*

Date

mm-dd-yyyy

I ______ authorize this SSS project to use my student’s name, statements and likeness, without charge, for promotional purposes in the project’s publications, advertising, video, and other formats..*

DODO NOT

Student Signature*

Date

mm-dd-yyyy

This is to certify that all of the information on this application is true to the best of my knowledge.

Parent’s Signature

Date

mm-dd-yyyy

APPLICATION