______________________________________________________________ _____________________
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.
click to sign
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome