EOC Long Application Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Social Security Number* PhoneEmail* Tell Us About YouGender* Male Female Age Date of Birth* MM slash DD slash YYYY Ethnicity* Asian American African American/Black Caucasian/White Hispanic/Latin Native American or Alaska Native Which one of your parent(s) completed a 4-yr (Bachelor) degree?* Neither Mother Father Both Citizenship* U.S. Citizen Permanent Resident Alien Military Connected to the Military Veteran Other I have a Disability English as Second Language Describe HouseholdTotal Family Adjusted Gross Income* No Income 17,655 or less 17,655-23,895 23,896-30,135 30,136-36,375 36,376-42,615 42,616-48,855 48,856-55,096 55,097-61,335 61,336 or more Household Size* 1 2 3 4 5 EducationalEducation Background* Did NOT complete High School High School Senior Currently enrolled in a GED/High School Diploma Completion Program High School/GED Never attended College Attended College -did NOT complete Currently enrolled in College Please list any College you attend or attended.Please list any College you attend or attended. Educational Goals I want to complete my GED/Obtain High School Diploma Obtain Associates Degree Obtain Bachelor's Degree I Plan to Enroll* Fall Spring Summer Part-Time (11 or less credit hours) Full-Time (12 or more credit hours) Desired Major or Career Goal How Committed are you to your Educational Goals Very Somewhat Not Very What Do You Need? Admissions Application ACT Accuplacer Compass Enrollment in College Financial Aid Sign the ApplicationI am interested in participating in the Educational Opportunity Center (EOC) project in order to achieve my educational/career goals. I certify the information provided herein is correct to the best of my knowledge. I authorize EOC to use the information contained herein for participation in the EOC project, and to request/receive copies of transcripts, financial aid awards, test scores, college and/or technical school enrollment information, and other relevant information necessary for participation in the EOC project. I further grant state and federal agencies permission to provide information as requested. EOC may share my information with the host institution as well as other institutions of my choice when applicable. Consent* I agree to the privacy policy.Name* First Last Date* MM slash DD slash YYYY Signature
