Fillable APPLICATION FOR SERVICES (Pensacola State College)

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APPLICATION FOR SERVICES (Pensacola State College)

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Country of origin: US
File type: PDF

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APPLICATION FOR SERVICES
Name: Last, First, MI DOB: Date:
Street Address:
City, State, Zip
Phone 1:
Phone 2:
E-mail Address:
Gender:
Marital Status:
Ethnicity:
VUB may text message me. I understand that I am responsi-
ble for any charges from my carrier. Standard text rates may
apply.
Are you a US Citizen?
If no, Alien registration #:
Did either one of your parents or guardians, who raised you,
graduate from a 4-year college/university before you were 18?
Did you serve at least 181 day of active duty?
Are you a Veteran?
Branch of Service:
Date of Discharge:
Type of Discharge:
Education benefit plan:
Highest level of education:
Credit hours accumulated:
Employment:
Were you discharged with or currently have a service-connected disability? Current rating: ______%
Which Veterans Upward Bound services are you interested in? (check all that apply)
Assessment of academic skills
Development of an education/ career
plan
GED completion
Assistance with Financial Aid
Veterans’ benefits applications
Community/ veterans’ agencies and
supportive services referrals
Assessment of career interests
Assistance with post-secondary school
applications
Information about college degree plans
and programs
Study Skills
College visits/ tours
Academic refresher courses
Mathematics
Science
Reading/ Writing Computer
Skills
Foreign Language
Other: ______________________________________________________
Feb 20, 2020
No
No
APPLICATION FOR SERVICES (continued)
After completing the Veterans Upward Bound program, what are your educational plans?
Community College
Vocational / Technical School
GED only (no school after VUB)
College/ University
Employment only
(no school after VUB)
If you are planning to continue your education what degree and/or course of study/program are you interested in.
__________________________________________________________________________________________
I would like to participate in the Veterans Upward Bound program, hosted by Pensacola State College, and receive the free
services provided. I hereby certify that the information provided in this application is accurate and complete to the best of my
knowledge.
I agree that if I am accepted in the VUB program, the staff may include my name and/or picture in publications, including
their website. These publications highlight student accomplishments and participation in VUB activities.
Confidentiality Statement: All infor mation provided is kept confidential and is shared among the VUB staff and other
college officials only on a need-to-know basis. The following limits to confidentiality apply: When child/elder abuse is
disclosed, when a threat to self or others is disclosed, or when records are legally subpoenaed.
Affidavit/Release of Information: I certify that the information I have provided on this application is to the best of my
knowledge, complete and accurate. I hereby authorize the VUB program and all other appropriate college departments,
including Financial Aid, to share academic and Financial Aid records that will help in assessing my academic and career
planning needs. I understand, in order to confirm or facilitate transfer and graduation, my information may be shared by or
with other postsecondary institutions or organizations, such as the National Student Clearinghouse. I also authorize the VUB
program to print my name and photograph, as appropriate in articles in the VUB newsletter, social media, and promotional
materials.
Pensacola State College does not discriminate against any person on the basis of race, ethnicity, national origin, color, gender/sex, age,
religion, marital status, pregnancy, disability, sexual orientation, gender identity, or genetic information in its educational programs,
activities or employment. For inquiries regarding Title IX and the college’s nondiscrimination policies, contact the Executive Director, for
Institutional Equity and Student Conduct at (850) 484-1759, Pensacola State College, 1000 College Blvd., Pensacola, Florida 32504.
INCOME VERIFICATION FORM
Print Name: ________________________________________________________________
All documents will be signed in person.
Documents will be emailed to vetsupbound@pensacolastate.edu
Size of
Family
Unit
48 Contiguous States, D.C., and
Outlying Jurisdictions
What is your Family
TAXABLE Income
for 2018?
What is your Family
NON-
Taxable Income for
2018?
1 $19,140
2 $25,860
3 $32,580
4 $39,300
5 $46,020
6 $52,740
7 $59,460
8 $66,180
How many people are
dependent of this income
(include yourself)?
Did you file a tax return
for the most recent tax
year?
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Completed 25 August 2020

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