Marital Status: Single __ Married __ Divorced __ Separated __ Widowed __
Are you a New York State resident? Yes ___ No ___
If yes, how long? ________________years _______________months
Are you a United States citizen? Yes ___ No ___
If no, please provide your alien registration number______________________
Are you a veteran of the United States Armed Forces? Yes □ No □
Are you supporting a dependent? Yes ___ No ___
Part 2 – Educational Information
Your intended academic major: _________________________________________________
Name of high school you graduated from or expect to graduate from:
High School GPA: __________
Expected date of HS graduation: ______/______/______
Type of Diploma: Regents □ Regents with advanced designation □ Local □ IEP (Individualized
Educational Program) □
If not a graduate of a New York State high school, did you receive a high school equivalency
diploma? Yes ___ No ___
If yes, provide the date: Month______ /Year______ Score: _____________
Part 3 – Educational Goal
Please identify your educational goal as an EOP student:
___ I plan to complete a certificate program
___ I plan to graduate with an Associate’s Degree
___ I plan to transfer to a four-year college or university and pursue a Bachelor’s Degree
___ I am undecided at this time.
Part 4 _ Summer Program Requirement
Being part of EOP requires commitment to the program and to yourself! As a way to help you
better prepare for the rigors of higher education, you must attend a three (3) week summer
program, which will offer a rich college experience full academics and interactive activities. The
summer program is mandatory for all incoming students and is being offered July 20
- Aug 7
Will you be able to attend the summer program during these dates?
___ Yes, I am excited to attend and get ready for my academic future!
___ No, I will not be able to attend the summer program.*
*you are automatically disqualified from joining EOP. Please see staff for details.