Frank Phillips College
Student Financial Services PO
Box 5118
Borger, TX 79008-5118
Student Data Form
READ CAREFULLY- ALL SPACES MUST BE ANSWERED
Student Name
Last First
Middle
Permanent Mailing Address
Street City State
Zip
Cell Phone Work Phone Home Phone_
To receive aid, you must be seeking a degree or certificate at Frank Phillips College, and your program of
study must be one that is eligible for financial aid and the classes you enroll in must apply to your
degree or certificate. Program of study (Do NOT leave blank)
High School Graduation Date GED completion date
Did you graduate with Recommended, Distinguished or Honors status? Yes or No
Prior college? Yes or No if yes, what college and date? MMDDYY
STATEMENT OF STUDENT ELIGIBILITY
Have you ever been convicted of a felony or an offense under Chapter 481, Health and Safety Code (Texas
Controlled Substances Act), or under the law of another jurisdiction involving a controlled substance as
defined by Chapter 481, Health and Safety Code?
No
Yes*
Have you been convicted for the possession /sale of illegal drugs in a federal/state court while you were
attending college? No
Yes*
*
If yes, please contact Student Financial Services.
The student is responsible to notify SFS of any class changed, (drop, withdrawal) from the initial
enrollment. The student is responsible to repay any overpayment made to the student as a result of a
class change. The student is responsible to notify SFS of any conviction from this date forward.
REQUIRED STATEMENT OF SELECTIVE SERVICE STATUS
For Males Only: Are you currently registerd for Selective Service, as required by federal law?
Registered
(Proof of registration required)
Not Registered
Exempt
(Documentation required)
I,
, hereby certify that the selective service status provided is true and correct. I
understand that I must provide documentation if requested by my institution that I may be required to complete a
new statement for each academic year for continued eligibility. All other information is also true and correct on
this form. If I fail to provide accurate information, I may be required to reimburse Frank Phillips College any
federal/state funds used on my behalf and additional penalties may be imposed.
Are you a displaced homemaker?
Are you academically disadvantaged?
Do you have a physical/mental impairment?
Are you a single parent?
Are you economically disadvantaged?
Student Signature
Date
Frank Phillips College is an equal opportunity education institution and employer. Its students and employees are
selected and/or assigned without regard to age, race, color, creed, sex, national origin, or disability, consistent w
ith
Titles VI and VII of the Civil Rights Act of 1964, and Title IX of the Higher Education Act amended in 1972, and Section
504 of the Rehabilitation Act of 1973. The compliance coordinator for Title IX is Dr. Shannon Carroll (scarroll@fpctx.edu;
806-457-4200, ext. 732) and Section 504 is Becky Green (bgreen@fpctx.edu; 806-457-4200, ext. 777).
click to sign
signature
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