2015-16 STUDENT APPLICATION
Veteran Student Support Services (SSS/TRIO)
PERSONAL DATA *all information will be held in strict confidence in compliance with the Family Educational Rights and Privacy Act
Century Student ID #:______________________________ (required)
Name__________________________ _____________________________ ______________________
Last First Middle
Phone Home (_____)___________________ Work (_____) ___________________________
Cell (_____)____________________ E-Mail address: ___________________________
Birth Date: Month ______ Day _____ Year _____ (required)
Gender: (Mark with an X) Citizenship Status:
__ 1. Male ___ U.S. Citizen
__ 2. Female ___ Resident Alien
___ Permanent Resident of Trust Territories
___ Other (______________________)
Please an X next to the statement qualifies you as a veteran for the purposes of the program:
_____ 1. Served on active duty for a period of more than 180 days and was released through conditions other
than dishonorable.
_____ 2. Served on active duty and was released due to a service connected disability.
_____ 3. Was a member of the reserve component of the Armed Forces called to active duty for more than 30
days.
_____ 4. Was a member of the reserve component of the Armed Forces who served on active duty in support
of a contingency operation on or after September 11
th
, 2001.
PARENT EDUCATION
Place an X in the box that indicates the highest level of education completed by your parents?
Grade
School
(grade 1-6)
High
School
(grade 7-12)
Some
College
(No
Degree)
2-Year
College
Degree
(Associate’s
Degree)
4-Year
College
Degree
(Bachelor’s
Degree)
Graduate
Degree
Unknown
Parent 1
Parent 2
STUDENT DISABILITY INFORMATION
*Answering the following questions is OPTIONAL, although please note it may affect your ability to qualify for the TRIO SSS Veterans
program.
1. Are you registered with or receiving disability services through Century’s Access Center? yes no
2. If no, have you ever been diagnosed with a disability or received a service-connected disability rating
through the VA? yes no
Minnesota State Colleges and Universities is committed to a policy of nondiscrimination in employment and education opportunity. No person shall be discriminated against
in the terms and conditions of employment, personnel practices, or access to and participation in, programs, services, and activities with regard to race, sex, color, creed,
religion, age, national origin, disability, marital status, status with regard to public assistance, sexual orientation, or membership or activity in a local commission as defined by
law.
This publication can be made available in an alternative format to individuals with disabilities by calling 651-779-3354, TTY 651-773-1715,
or through the Minnesota Relay Service at 1-800-627-3529
STUDENT EDUCATIONAL HISTORY
Do you plan to be enrolled full-time or part-time? Full-time Part-time
Do you plan to receive a degree from Century College? Yes No
If yes, what degree? _____________________________________________
Do you plan to transfer to a four year college/university?
Yes No
If yes, for what program? __________________________________________
How can we help you complete your goals? (check all that apply)
APPLICANT’S PERSONAL STATEMENT (please address the following points)
Briefly explain your educational and career goals.
What help might you need to complete your goals?
STUDENT CERTIFICATION and RELEASE
I, the above named applicant, certify that the information I have provided is complete and correct. I authorize SSS staff to obtain
records or data in support of my application from other sources, and to release information as required by the grant-funding agency of
the United States Government. I agree that if I am accepted into SSS, program staff may have access to my academic and financial
aid records and may include my name as a participant in SSS publications. Note: SSS is a federally funded TRIO program. The US
Dept. of Education requires reporting by Social Security number. If accepted into the program, you will be required to provide
this information.
_____________________________________ _____________________
Student Signature (Please type student name) Date
Advising and Career:
Understanding/Applying for
VA/Military Benefits
Career Planning
Choosing a Major
Transfer Planning
Goals/Decision Making
Financial Aid Advising
Other:
Financial Literacy
_________________________
__________
Academic Skills:
Time Management
Study Skills
Test Taking/Test Anxiety
Reading Comprehension
Writing
Organization
Note Taking
Math Skills
Basic Computer Skills
Tutoring
Learning Strategies
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