Fillable 2017-2018EOPSAPPLICATION

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2017-2018EOPSAPPLICATION

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The 2017-2018EOPSAPPLICATION form is 2 pages long and contains:

  • 1 signature
  • 51 check-boxes
  • 51 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Las Positas College

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2017-2018 Application
Birthdate:
/ /
Age
HAVE YOU:
A.
Applied for EOPS before? Yes No
If Yes, what year(s):
What College(s):
Yes
No
C.
Participated with Disabled Students Program & Services (DSPS) and/or Learning Skills?
D.
Participated with CalWORKS?
Yes No
E.
Attended
another college?
Yes
No
F.
List all colleges attended
(
including Las Positas
):
College Name
City/State or County
Dates Attended
From mo/yr -to- mo/yr
Degree(s) Earned
RESIDENCY
A.
California Resident
B.
U.S. Citizen
Yes
Yes
No
Lived in California since: Month Year
No Immigrant-Permanent Resident (green card holder)
Yes
No
1.
2.
3.
Last Name
First Name
W#
Address
Telephone (H)
(C)
City State
ZIP
Male
Female
Email
Last Name
Preferred Name
FAMILY BACKGROUND DATA
A.
Number of family members in your household: Number of your children:
Ages of your children:
Married
Separated Divorced Widowed
Marital Status:
Single
B.
Source of 2015-2016 Income
Employment Unem
ployment Compsensation SSI
CalWORKS/TANF
Parents
C.
Ethnic Background
African American Middle Eastern (country)
American Indian/Alaskan Native
Pacific Islander (country)
Asian (country)
Filipino
White (Caucasian)
Other:
Hispanic, Latino, Chicano
EDUCATIONAL INFORMATION (Check all that apply)
A.
Educational Goals
Associates Degree Transfer to a 4-year college or university Certificate Undecided
Name of transfer college or university:
B.
Major:
C.
Did your parent(s) graduate from a college or university (foreign or domestic)?
Yes
No
D.
Is English the main language spoken in the home?
Yes
No If "No," what languages?
E.
Are you a high school graduate?
High School last attended:
Yes
No
Name of High School: City/State or County
Date of Graduation:
F.
Did you receive a GED?
Yes No
If "Yes," when did you receive your GED? Month Year
G.
Are you receiving Veterans Educational Benefits?
Yes
No
H.
Have you ever been a Dependent of the Court or a Foster Youth?
Yes
No
CERTIFICATION: Read this statement and sign below:
I hereby swear or affirm, under penalty, that all information on this form is true and complete to the best of my
knowledge. I also realize that any false statement or failure to give proof when asked, may be cause for exclusion
from participation in the EOPS program.
** I give the EOPS/CARE Program permission to print my name in EOPS publications (i.e. EOPS newsletters,
website, recognition programs) to recognize my accomplishments.
Yes
No
Student Signature: Date:
High School GPA:
How did you hear about EOPS?
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2017-2018EOPSAPPLICATION

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Completed 3 January 2020

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