______ _________ _________________
______________________
Veterans Upward Bound
Name: ________________________ ____ _____________________________ SSN: ___________________
First MI Last
Address: __________________________________ _______________________
Street/P. O. Box City
Home Phone: ____________________ Work Phone: _________________
E‐Mail: _________________________________Date of Birth: _____________
Ethnic Background:
African American
American Indian/Alaskan Native
Asian
Hispanic
Native Hawaiian or Other Pacific Islander
White
Other (Please specify)_______________
Please answer the following questions:
Are you a U. S. Citizen?
Yes No
Employment Status:
State Zip Code County of Residence
Cell Phone:
Gender:
Male Female
Permanent Resident Alien?
Yes No
If Yes, INS Number__________________
Unemployed Employed full time Unknown
Employed part time Retired
1. Did you serve at least 181 consecutive days of active duty since January 31, 1955? Yes
2. If no, did you receive a medical discharge? Yes No
3. What type of discharge did you receive? _____________________________________________
4. What branch of service did you serve? __________________________________
5. Did either of your parents receive a bachelor’s degree? Yes No
6. What is your taxable income from your most recent tax return? ____________________
7. What is the total number of household members? ______
8. Do you have a documented disability? Yes No
No
Educational Status:
High school dropout
High school graduate
GED/high school equivalency
High school graduate with some college
GED/high school equivalency with some college
College graduate/Bachelor’s degree or higher
Are you enrolled in college at this time?
Yes No
If yes, are you: ___Enrolled for first time
___Continuing from last semester
___Returning after stop out
College Attending: ______________________
How did you learn about VUB?
Referral from community agency: __________________
Advertisement
Website
College Counselor
Word of mouth/Walk‐in/Call‐in
Referral from another TRIO program
Other
I am interested in the following services:
Free college preparation courses
Assistance with college selection and applications
Assistance with financial aid
Academic success workshops
Academic/Career counseling
Job Search Clinics
By signing below, I authorize the Veterans Upward Program to obtain information to verify my eligibility for services. Such information might
include copies of Federal Income Tax Returns, FAFSA Applications, other documentation for income eligibility, DD-214 or other military
service eligibility, transcripts of academic or military training programs, and college transcripts of current and past academic performance.
I understand that all information provided is CONFIDENTIAL and will not be disseminated without my ex press permission. The information
included above is true and accurate to the best of my ability.
___________________________________________________ ___________________________________
Signature Date
Revised Aug/2010
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