Fillable LMC EOP Sapplication (Los Medanos College)

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LMC EOP Sapplication (Los Medanos College)

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Los Medanos College
Extended Opportunity Programs and Services (EOPS)
2700 Leland Road, Pittsburg, California 94565-5197 (925) 439-2181 x3138 Fax: (925) 427-1599
Term Applying:
I. APPLICANT INFORMATION
II. ETHNIC BACKGROUND
Is English your Primary language?
School ID#
City
State
Zip Code
E-mail Address
Phone #
Lastname
Firstname
MI
Marital Status
Summer 2006
Fall 2006
Spring 2007
M F
Gender:
Children
Name:
Age:
Date of Birth
Date of Birth
Ethnicity
:
African American/Black
American Indian
Asian
Chicano/Latino
Caucasian/White
Middle Eastern
Pacific Islander
Pilipino
Decline to State
(specify)
Yes
No
If no, please indicate language:
Address
Apt.#
mm/dd/yyyy
Name:
Name:
Age:
Age:
Date of Birth
Date of Birth
III. ECONOMIC BACKGROUND
Total Number in household, including yourself:
Receiving TANF/CalWORKs: Time on TANF:
Receiving SSI; General Assistance; Refugee Assistance or any other type of assistance:
Please Specify:
mm/dd/yyyy
(specify)
(specify)
Language
IV. EDUCATIONAL BACKGROUND
o
High School:
Received:
HIgh School Diploma
GED
Non-Grad
GPA
Year:
o
College:
Do you hold any college degrees/certificates?
Yes
No
Type:
Please list ALL colleges you have attended below:
College or University
Address
City
State
Units
Dates
College or University
College or University
Address
Address
City
City
State
State
Dates
Dates
Units
Units
Parent(s) Academic History:
Non-HS Grad HS Grad, no college
College Grad
Years of College:
Years of College:
Where:
Where:
Degree
Degree
HS Grad, no college
Non-HS Grad
College Grad
Mother-
Father-
Student Academic History:
V. EDUCATIONAL GOAL
To obtain a certificate or license
To acquire new job skills
To complete credits for a High School Diploma:
None of the above apply; specify
To obtain an A.A./A.S degree; field
To transfer to a four year institution with an A.A. degree; where
To transfer to a four year institution without an A.A. degree; where
Have you completed the 2006-2007 FAFSA Application?
Yes
No
If your answer is no, your acceptance into the EOPS Program is based on a provisional status.
Certification:
I attest all information is true and complete to the best of my knowledge. I realize that any false statements
or failure to provide proof where required may be the cause for denial or being ineligible for the Program. By
signing this application, I authorize EOPS/CARE staff to verify any and all information provided and exchange
such information with necessary offices/programs.
Signature of Applicant
What is your training/educational goal:
Submit
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LMC EOP Sapplication (Los Medanos College)

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Completed 18 July 2020

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