______________________________________________________________ _____________________
Student’s Signature Date
TRIO Student Support Services
Application Form 2019-2020
______________________________________________________________________________
First Name: _______________________ M.I. _____ Last Name: ________________________________
Student ID Number: N___________________________________________________________________
Street Address: ________________________________________________________________________
City: ________________________________ State: _________ Zip Code: _________________________
SMC Wired E-Mail Address: ______________________________________________________________
Cell Phone Number: _(________)________________________________________________________
Gender: Male □ Female Birth Date: _________________________________________________
Are you either a U.S. Citizen or a U.S. Permanent Resident? □ Yes No
What is your Ethnicity? American Indian/Alaskan Native Asian African American/Black
Hawaiian/Pacific Islander White Hispanic/Latin American
Do you have any documented physical or learning disabilities (optional)? □ Yes No
If yes, please explain: __________________________________________________________
Has either your mother or father received/earned a 4-year college degree? Yes No
Do you receive Financial Aid? Yes No Have you been offered a Pell Grant? Yes No
By signing this application I attest that all the information on this application is true.
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