Fillable Lake Michigan College - EOC Application

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Lake Michigan College - EOC Application

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Country of origin: US
File type: PDF

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Director
L.E.P
2755 E. Napier Avenue Benton Harbor, MI 49022 269-927-8100 Toll-free: 800-252-1562 Fax 269-927-8175
The Educational Opportunity Center is funded by a US Department of Education grant
DEMOGRAPHIC DATA (Please Print)
Application Date ______________________
Name: ______________________________________________
Last First Middle Initial
Address: ______________________________________________
Street
______________________________________________
City State Zip County
Permanent Address: ____________________________________
Street
_____________________________________________
City State Zip County
Home Phone ________________ Cell Phone ______________
Email Address _________________________________________
*Social Security #: --
*required for EOC services
Date of Birth: // Age ______
Place of Birth: ________________________________
(City, State, Country)
GENDER:
[ ] Female
[ ] Male
MARITAL STATUS:
[ ] Single with (Children) Dependents/head of household
[ ] Single
[ ] Married Date: ______
[ ] Divorced Date: ______
[ ] Separated Date: ______ [ ] Widowed Date: ______
ELIGIBILITY
INFORMATION:
[ ] Employed
[ ] Unemployed
[ ] Disabled
[ ] Public Assistance
[ ] Social Security (SSI)
[ ] Incarcerated
Release Date: __________
DOC #: _______________
BACKGROUND:
Mother has a 4 year college degree
YES NO
Father has a 4 year college degree
YES NO
RESIDENCY STATUS:
[ ] Citizen of the US
[ ] US Naturalized
(obtained Citizenship)
[ ] Legal Resident
(green card, visa, etc.: Documentation Required)
[ ] other _______ (Documentation Required)
MILITARY STATUS:
[ ] Veteran
[ ] Active duty
[ ] Registered with Selective Service Board
(Male 18 and older) [ ] unknown
[ ] Are you the spouse or a child of an
active duty military person?
SPOUSE CHILD
[ ] Not applicable
FAMILY SIZE
(# you claim)
Fill in circle
2018 FEDERAL LOW
INCOME GUIDELINES
$18,210
$24,690
$31,170
$37,650
$44,130
$50,610
$57,090
$63,570
Please Check: I hereby certify, under penalty of
perjury, that my taxable income
Does Does Not
Exceed the levels listed above on the size of my
family unit.
EDUCATIONAL STATUS
2/19/2018 kw
Educational Opportunity Center
At Lake Michigan College
Program Application
Site: _______________________________
Example: Business/HVAC/CAD/Dentistry/Nursing
STATEMENT OF RELEASE OF INFORMATION AND CONFIDENTIALITY
Lake Michigan College Educational Opportunity Center
Ethnicity/Race Questionnaire (Supplement to EOC Application)
Please read and respond to the questions. Definitions are provided to clarify each category.
Question 1:
Are you, the student applicant, Hispanic/Latino?
Check only one: Yes No
Question 2:
To which racial group(s) do you belong?
Check all that apply: (see definitions to right)
American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
White
___________________________ _________________________ __________
Student Name (Printed) Student Signature Date
2/19/2018
Definitions (as determined by the U.S Department of Education)
Hispanic/Latino: A person of Cuban, Mexican, Puerto Rican, South or
Central American, or other Spanish Culture or origin, regardless to
race.
American Indian or Alaska Native: A person having origins in any of
the original peoples of North and South American (including Central
America and who maintains a tribal affiliation or community
attachment.
Asian: A person having origins in any of the original peoples of the Far
East, Southeast Asian, or the Indian subcontinent including, for
example Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the
Philippine Islands, Thailand, and Vietnam.
Black or African-American: A person having origins in any of the Black
racial groups of Africa
Native Hawaiian or Other Pacific Islander: A person having origin in
any of the original peoples of Hawaii, Gran, Samoa, or Pacific Islands.
White: A person having origins in any of the original peoples of
Europe, the Middle East, or North Africa
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Lake Michigan College - EOC Application

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Completed 29 April 2020

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