Cohort _________________ Date Received by SSS: _______________
STUDENT SUPPORT SERVICES APPLICATION
Northeastern Oklahoma A&M College
Date: ________________________ NEO ID#: ____________________________
Name: _______________________________________ _____________ _____________________
(Last) (First) (Middle Initial) (Maiden Name)
Cell Phone: __________________________________ Live On Campus Off Campus
Local address: ________________________________________________________________________
Street/Apt # City State Zip
Permanent Address (if different):________________________________________________________
Street/ Apt. # City State Zip
NEO E-Mail: ___________________________ Personal E-Mail:_______________________________
Are you a U.S. Citizen? Yes No Date of Birth: __________ Gender: Male Female
Ethnicity: Are you Hispanic or Latino? Yes No
Please select one or more choices below that identify your race(s):
American Indian or Alaska Native Asian
Black or African-American Native Hawaiian or Other Pacific Islander
White
Dependency Status (select all that apply):
Both Parents are Deceased Have Dependent Children 24 Years of Age or Older
Armed Service Veteran Ward of the Court Married
If you checked NONE of the above, you are considered a Dependent student and must submit your signed parent’s or
guardian’s income tax information. We only need the first 2 pages of the federal tax return. SSNs may be blacked out.
If you checked at least ONE of the above, you are considered an Independent student and must submit your own income
tax information.
Place a mark in the box that represents the highest level of education completed by the parent(s) or
legal guardian(s) with whom you grew up prior to the age 18. Leave area blank if not applicable.
Less than High
School Diploma
High School
Diploma/GED
2-year college
degree
4-year college
degree or higher
Mother
Father
Legal Guardian
Other
Foster Care Lived with non-legal guardians Homeless
Do you have a college degree? Yes No
Over
Have you attended a college or university before and earned college credit? Yes No
Have you ever been on academic/financial aid probation or suspension? Yes No
Are you interested or do you plan to earn a 4-year college degree somewhere? Yes No
Do you have a documented disability? Yes No
Are you registered with the Office of Disability Services at NEO? Yes No
Have you selected a college after NEO? Yes No Transfer College________________________
Do you have a Major? Yes No Major: _________________________________________
Do you have an Advisor? Yes No Advisor: ________________________________________
My academic goal is to… _______________________________________________________________
In the following section, please indicate what assistance you believe would be useful to you to
achieve your academic and or/career goals.
Tutoring and Study Skills to Raise Grade(s)
Financial Aid Information/FAFSA Assistance
Academic Advising and Course Selection
Financial Education (Budgeting/Credit Counseling)
Career Assessment and/or Advising
Community Service/Cultural Events
Mentoring and/or Personal Counseling
Transfer Assistance to a 4-year institution
In addition to items checked above, are there other reasons you are applying for Student Support Services
or are there additional obstacles that may prevent you from completing your academic goal(s)?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Verification and Release of Information:
The above information is true and complete. I understand it is confidential and will be used for statistical
purposes. Further, I release the following information to SSS to verify eligibility, determine appropriate
services and to track academic progress:
Mid-term and Final Grades Transcripts/Registration Information
Financial Aid Information Standardized Test Scores (ACT/SAT)
Income Information (1040) Transfer Information
Contact professors/advisors Release name for recognition, scholarships, etc.
Student's Signature: ________________________________ Date: _______________________
NEO A&M College Student Support Services is 100% federally-funded at a cost of $278,277 and does not discriminate on the basis
of age, race, color, religion, sex, sexual orientation, genetic information, gender identity or expression, national origin, disability,
protected veteran status, or other protected category, in any of its policies, practices or procedures. This provision includes, but is
not limited to, admissions, employment, financial aid, and educational services.
Revised 2/4/19
Mother’s Name
Father’s Name
If Other Than Parent
Relationship
Emergency Contact Name: _______________________________ Telephone #:_________________
Relationship: ___________________________________________Alt #: _______________________
click to sign
signature
click to edit
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