East Central University-EOC-Application Form

Name:

First NameLast Name

SSN #:

999-99-9999

Date of Birth:

mm-dd-yyyy

County of Residence:

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Telephone:

(999)999-9999

E-mail:

example@example.com

Marital Status:

Month and year if married, separated, divorced, or widowed:

Sex:

Did either of your parents complete a four-year degree?

Are you currently a participant in another TRiO program (Upward Bound, Talent Search, Student Support Services, etc)?

If yes, in which program are you a participant?

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

Active Duty?

Are you the spouse or child of active duty military?

Are you a U.S. citizen?

If no, are you an eligible non-citizen?

Alien Registration Number:

A-

Race: (check all that apply)

Have you completed a FAFSA?

Did someone come to your high school to help with a FAFSA?

Which high school?

FINANCIAL STATUS

What is the size of your household?

Family’s Total Adjusted Gross Income:

Household Funding Sources:

Monthly Amt?

HIGHEST LEVEL OF EDUCATION

Where?

Last Grade Attended and School

SERVICES NEEDED

NOTES:

I have been given the opportunity to participate in any services offered by EOC. I authorize the EOC Program to release academic and financial aid information to assist me with my education. To the best of my knowledge, all information given on this application is correct.

Signature:

Date:

mm-dd-yyyy

Name:

First NameLast Name

SSN #:

999-99-9999

Educational Opportunity Center

100 E 14th St., PMB S-56

Ada, OK 74820

(580) 559-5684 FAX: (580) 559-5778

CONFIDENTIAL

Release of Information

Your signature below gives EOC counselors permission to obtain your enrollment status and any documentation necessary from the college you are attending.

I, {name}, SSN {ssn56},

Authorize East Central University (ECU) Educational Opportunity Center (EOC) personnel the access or release of academic and/or financial information and documentation, including but not limited to academic and financial aid transcripts, as necessary to assist me in achieving my goals or in meeting the reporting requirements of the U.S. Department of Education.

Participant Signature:

Date:

mm-dd-yyyy

EDUCATIONAL OPPORTUNITY CENTER

FINANCIAL STATUS

HIGHEST LEVEL OF EDUCATION

SERVICES NEEDED

NOTES

Release of Information