Student ID#___________________________ SS#______________________________
Applicant Name: (Last, First Name )_____________________________________________ (MI)___
Address: _________________________________________________________________________________________
(Street/P.O. Box)
(City) (State)
(Zip Code)
Home Phone: (____) _________________ Work Phone: (____) _____________ Cell Phone: (____) ________________
Email Address:_________________________________________
Gender: Male Female
Yes No
Can We Send You Text Messages:
Birth date: ______/______/_____
MM
DD
YY
PART 1: PERSONAL DATA
PART 2: ETHNIC/ITY/ RACE/ CITIZENSHIP GROUP
Are you Hispanic/Latino? Are you an eligible non-citizen?
Yes No Yes No
Alien Registration Number:
Are you a U.S Citizen?
Yes No —————–————————--
Select a RACE:
Caucasian/White
African-American/Black
American Indian/Alaska Native
PART 3: MARITAL STATUS
Single
Married Divorced Separated Widowed
PART 4: EDUCATIONAL INFORMATION
Did you receive (check one): High School Diploma or GED
Name of school ________________________________________________Year_________________
Have you attended a college other than OJC?
Date you started at OJC________________________
Do you plan to attend college? Full-time Three-quarter time
Yes No If so, where?
Less than half-time
Target completion date at OJC? Do your goals include transfer to a 4-year college? Yes No
If you plan to transfer to a 4-year college, when?_______________ Name of college: ______________________________
Which OJC degree or certificate are you planning to pursue?
(Check the one that applies to you)
Associate of Arts (AA — transfer degree)
What is your major?
Associate of Science Degree (AS — transfer degree)
What is your major?
Associate of General Studies (AGS — non-transfer degree)
What is your major?
Associate of Applied Science (AAS — non-transfer degree)
What is your major?
Certificate ____________________________________________________
Participant Application
Native Hawaiian/Pacific Islander
Asian
Half-time
Check if you have a Degree?
PART 6: FIRST GENERATION VERIFICATION
Did your mother earn a 4-year college degree?
Did your father earn a 4-year college degree?
Which parent did you regularly reside with and receive
support from before the age of 18?
PART 7: DISABILITIES VERIFICATION
Do you have any documented physical and/or learning disabilities? Yes No
If yes, is the disability information on file with the Otero Junior College Disability Office. Yes No
PART 8: INCOME VERIFICATION
PART 10: RELEASE OF INFORMATION
I authorize the TRiO Student Support Services Program staff to:
gather information concerning all my academic progress (standardized test scores, grade point average, earned credit, tran-
scripts, tutoring, etc.) and financial aid reports including Federal tax, FAFSA and verification of income prior to my participa-
tion in the program
obtain information from the ADA office if I fall under the disability status
gather information for follow-up whenever appropriate, including, but not limited to, transfer and progress to 4-year institu-
tions
report my eligibility, GPA, and financial aid status to the U.S. Department of Education in accordance with the grant funding
regulations
use my name, photo, or information about me in all college media sources and on the TRiO Facebook page
The information provided on this form is, to the best of my knowledge, accurate and true.
Student ________________________________________________________________ Date____________________
TRiO Staff ______________________________________________________________ Date ____________________
PART 9: WORKSHOPS AND SERVICES (check all that you could use help with)
Scholarship Tips
Resume Writing Tips
Time Management Tips
Vocabulary/Math Skills
Tips for Relieving Stress
Help Setting Goals
Academic Advising
Cultural Events
Transfer Advisement
Campus Tours
Study Habits Tips
Test Taking Skills
Help Managing Money
Which of the following services are you interested in receiving?
Financial Aid Advisement
Personal Counseling
Tutoring
Career Counseling
Note Taking Tips
Help Navigating the Computer
Enhance Memory
Yes No
Yes No
Mother Father Both
Neither
Verification requirements for TRIO SSS vary depending on whether
students are Independent or dependent. A list of federal criteria for
independent student status is available at www.fafsa.ed.gov.
Part A: Independent Students (typically age 24 or older,
married, or emancipated; parental income is not reported on
the FAFSA): complete Part A.
Independent Student:
Total Number of Exemptions or total number of people claimed
in household: __________
*Taxable or total Income: $________________
____________________________ ________________
Student Signature Date
*Form 1040 line 43, or Form 1040 A line 27, or Form 1040 EZ line 6. If
taxes were not filed, please report total income from all sources.
Part B: Parent/Guardian (Dependent Student Only)
Dependent student (younger than 24., unmarried or not emancipated;
parental income is reported on the FAFSA): parent/guardians must com-
plete and sign Part B.
Dependent Student:
Total Number Exemptions or number of people claimed in house-
hold:_____________
*Taxable or total income: $____________________
_____________________________
Parent/Guardian Name (please print)
_________________________________ ______________
Parent/Guardian Signature Date
*Form 1040 line 43, or Form 1040 A line 27, or Form 1040 EZ line 6. If taxes were
not filed, please report total income from all sources.
PLEASE PROVIDE THE FOLLOWING INFORMATION WHEN YOU BRING IN YOUR APPLICATION
1. Signed 20xx Federal Income Taxes/or Proof of Income/or Fixed Income Statement (if you did not fill out Part 8)
2. Disability Verification letter from OJC Disability Office, if applicable
3. Documentation of Citizenship, if applicable
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