Fillable Application Update 1.8.18 Fillable ENMU-ROSWELL

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Application Update 1.8.18 Fillable ENMU-ROSWELL

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U.S.A. forms for Montana State University - Billings

BROWSE MONTANA STATE UNIVERSITY - BILLINGS FORMS

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Updated 7/29/15 The SSS TRIO program is 100% federally funded. Page 1 of 5
Student Support Services TRIO
Participant Application
Library 141 657-2162 657-1667 (fax)
Demographic Information
Name:
First M.I. Last Former Names/Maiden Name
Local Address:
Number & Street City State Zip
Telephone: Email:
SS#: Student ID #: DOB:
Month/Day/Year
Gender: ______________ # in Household:_______ Are You A Single Parent? Yes □ No □
Marital Status: Single □ Domestic Partner □ Married □ Separated □ Divorced □ Widowed □
Ethnicity: Hispanic/Latino? Yes □ No □
Race: American Indian or Alaskan Native □ Tribe:________________________________
Black or African American □ Native Hawaiian or Other Pacific Islander □
Asian □ White □ Other:______________________ More than one race □
Primary Language: (Please Identify)
Graduated from High School: OR Received GED/TABE:
M/YY (Circle One) M/YY
Name of School:____________________ Location:___________________
City/State
Are you a U.S. Veteran? Yes □ No □ If yes, which branch?
Enrollment Information
When did you first enroll at MSUB?
M/YY
I am currently enrolled at: MSUB University □ MSUB City College □
How many hours/credits are you taking this semester?
0-5 (less than part-time) □ 6-8 (part-time) □ 9-11 (three-quarter time) □ 12+ (full-time) □
SSS TRIO Participant Application
Updated 12/08/17 The SSS TRIO program is 100% federally funded. Page 2 of 5
Have you attended any other colleges/universities? Yes □ No □
Please list
Date Institution Location
Date Institution Location
What is your academic goal?
□ Bachelor’s Degree (4 Year) Intended Major:
□ Associate’s Degree (2 Year) Intended Major:
□ Pre-professional Program Intended Major:
□ Transfer to another school
Financial Aid (Check all that you are receiving):
□ Federal Financial Aid □ Tribal Funding □ Workers’ Comp □ Scholarship
□ Voc. Rehab. □ VA □ Self Pay □ Other:
Eligibility Information (please circle the appropriate answer)
Do you have a Bachelor’s Degree (4 Year)? Y□ N□
Did the parent/guardian you lived with until age 18 have a Bachelor’s Degree? Y□ N□
Do you have a documented emotional, physical, or learning disability? Y□ N□
Do you take any medications for emotional reasons (i.e. anxiety, depression
ADHD, etc.)? Y□ N□
If you answered yes to either of the last two questions, please provide documentation.
Are you a United States citizen? Y□ N□
Are you in foster care or aging out of the foster care program? Y□ N□
Do you lack a fixed, regular, and adequate nighttime residence? Y□ N□
Are you a former TRIO participant? Y□ N□
If yes, identify which program: __________________
UB VUB ETS EOC SSS McNair Math/Science UB
SSS TRIO Participant Application
Updated 12/08/17 The SSS TRIO program is 100% federally funded. Page 3 of 5
Income Verification Form:
Confidenial-All information will be held in strict confidence. Federal regulations require that verification of
income must be submitted as a part of the application process.
In order to verify income, applicants have two options:
1. Attach the most recent copy of the Federal Tax Form 1040, 1040A, or 1040EZ.
(If you attach a copy of a signed tax form it is not necessary to complete the rest of this page).
OR
2. Complete the following family verification information.
If a federal income tax was filed during the last calendar year please indicate your taxable income amount on the
following line and SIGN AT THE BOTTOM OF THE PAGE.
Family Taxable Income: Last Year $_____________________ (after deductions).
Line 43 from 1040 form
Line 27 from 1040A form
Line 6 from 1040EZ form
If you were not required to file an income tax return for the last calendar year, you must complete the following
section and SIGN.
I/We declare that no federal income tax return was filed by the undersigned for the last tax period and all
income received during the year was as follows:
SOURCE AMOUNT
___SOCIAL SECURITY $___________________________
___VETERAN’S BENEFITS $___________________________
___CHILD SUPPORT $___________________________
___WELFARE/SOCIAL SERVICES $___________________________
___UNEMPLOYMENT $___________________________
___RETIREMENT $___________________________
___OTHER $___________________________
TOTAL: $___________________________
I certify that all the above information is correct and complete to the best of my knowledge.
_________________________________ _____________________________ _______________
STUDENT’S SIGNATURE SOCIAL SECURITY NUMBER Date
_________________________________ _____________________________ _______________
PARENT’S/GUARDIAN’S SIGNATURE SOCIAL SECURITY NUMBER Date
(If you are a “dependent” student)
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SSS TRIO Participant Application
Updated 12/08/17 The SSS TRIO program is 100% federally funded. Page 4 of 5
General Information
How did you learn about Student Support Services TRIO or who referred you?
Please tell us about yourself; who are you?
What would you like to gain from being a participant in the SSS TRIO program?
Why did you choose to attend college?
What do you plan to do after completing your Bachelor’s degree?
SSS TRIO Participant Application
Updated 12/08/17 The SSS TRIO program is 100% federally funded. Page 5 of 5
Participant Consent and Authorization: Student Support Services TRIO
Release of Information
Student Support Services TRIO is a program designed to help you graduate. The information provided is
confidential and will help determine eligibility for the Student Support Services TRIO program. Discrimination
is prohibited on the basis of race, gender, color, national origin, religion, age, disability, marital or parental
status, or sexual orientation.
I hereby authorize Student Support Services TRIO to obtain and share any information pertinent to my
participation in the program. This information includes, but is not limited to, financial aid information,
standardized test scores, transcripts, and grade reports. I also verify that the information provided on this form
is correct and complete to the best of my knowledge.
I, _______________________________________, Student ID# ________________________,
(Print Student Name)
give Student Support Services TRIO and MSU Billings permission to discuss my files with all entities on the MSU-Billings
campus, to use my name/picture for public recognition as part of the Student Support Services TRIO Program and to share
information with the entities listed below (if applicable).
Any others you may wish SSS TRIO Staff to speak with (Voc Rehab, parents, etc.). Please print LEGIBLY:
_____________
___________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
This release is in effect from ________________________________ to ___________________________________
(If not designated, release is in effect until graduation)
Student Signature: ______________________________________ Date:______________________
Staff Signature: ______________________________________ Date:________________________
Date Application Recieved: ____________________
Interview Date:________________________
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Application Update 1.8.18 Fillable ENMU-ROSWELL

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Completed 17 April 2020

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