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Applicationtoparticipate2

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U.S.A. forms for Orange County Community College

BROWSE ORANGE COUNTY COMMUNITY COLLEGE FORMS

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Rev. 12/15 Page 1 of 2
Application to participate in:
Student Support Services (SSS) is a federally funded TRIO grant program through Title IV (TRIO) of the U.S. Department of
Education. SSS provides academic and personal support services to eligible students in an effort to assist them to successfully complete
their education and achieve their personal and career goals. SSS offers a wide variety of services and activities designed to meet the
individual needs of each student. All TRIO services are FREE to those who qualify. Any SUNY Orange County Community College
(OCCC) student may apply to participate in TRIO. Information obtained from this form is used only by SSS and kept strictly
confidential. It does not in any way affect your admission or eligibility to participate in other services and activities offered by the college.
Name: _____________________________________________________ Date of Birth: ____________
Last First Middle Initial
SSN: _________________ Student ID #: A Sex: Male Female
U.S. Citizen: Yes No Permanent Resident: Yes No
Ethnicity: (We are required to report this information. Your response does not affect eligibility for program services.)
- Please check one -
White African-American Hispanic/Latino Asian Native Hawaiian/Pacific Native American
Address: ______________________________________________________________________________
Street/PO Box City State Zip Code
Home Phone: ( ) _______________ __ Personal Cell: ( ) __________________
Email: __________________ Other:
How did you hear about TRIO SSS?
Marital Status: Single Married Divorced Widowed Veteran Status: Yes No
Educational Background: Less than high school diploma High school diploma H.S.E. Some college
Attended other college or university _______________________________________________
First Generation:
Has your mother completed a bachelor’s degree or higher? Yes No
Has your father completed a bachelor’s degree or higher? Yes No
Verification Information
Employed?
No Yes – Where ________________________________________________________
Check the amount below which best matches your current household’s level of taxable income: (To select an amount,
please refer to tax forms 1040EZ-line 6, 1040A-line 26, or 1040-line 43 ** leave bank if unknown**)
0 – $17,655 $17,656 – $23,895 $23,896 – $30,135
$30,136 – $36,375 $36,376 – $42,615 $42,616 – $48,855
$48,856 – $55,095 $55,096 – $61,335 Over $61,335
Total number in your household:
Disability:
Do you have any type of disability (ex. physical, medical, psychological, learning, attention deficit) or were you
ever in a special education program while in school?
Yes No
Are you aware we have a Disability Services office in the Shephard Center on the third floor?
Yes No
I certify that the above information is true and correct to the best of my knowledge. In addition,
everything mentioned in this application packet—(all forms) are verified by this signature. I hereby
authorize Student Support Services to obtain all academic and financial information necessary to
determine my eligibility.
Applicant Signature: Date:
OCCC is an equal opportunity/affirmative action institution.
OFFICE USE ONLY: Date Application Received:___________
Eligibility requirements met: First Generation / Income / Disability
Student Accepted Yes No Date:______________ Staff Initials____________
Reason Accepted_________________________________________________ APR #
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Applicationtoparticipate2

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Completed 12 March 2020

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