Eastfield College -- TRiO Application

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Student Services >> TRiO/SSS >> TRiO Application

Please print, fill out and return the form to Eastfield College Student Support Services, C237 or mail it to:

Eastfield College,
TRiO Application 3737
Motley Drive
Mesquite TX 75150

Eastfield College
Student Support Services
TRiO PROGRAM APPLICATION

Name:______________________________________ SS#:____________________Sex: [_] M [_] F

Address:_________________________________________________ D.O.B.:____________________

City:________________________________ Zip code:______________ Phone:___________________

E-Mail Address:____________________________ Career Goal/Major:___________________________

Do you plan to transfer to a 4-year institution? [_] Yes [_] No
What school do you plan to transfer to?_______________________________________________________

Race:
[_] American Indian	[_] Asian	[_] African-American
[_] Hispanic	[_] White (Non-Hispanic)	[_] Other

Number of persons, including yourself, in household?_______

Estimated taxable family income (please check one):
[_] $0 - $14,355	[_] $24,135 - $29,095	[_] $38,805 - $43,695
[_] $14,355 - $19,245	[_] $29,095 - $33,915	[_] $43,695 - $48,585
[_] $19,245 - $24,135	[_] $33,915 - $38,805	[_] more than $48,585

Are you currently receiving financial aid? [_] Yes [_] No
If yes, what kind?__________________________________________________________________

Did either of your parents receive a Bachelor's Degree? [_] Yes [_] No

Do you have a physical, mental, or learning disability? [_] Yes [_] No
If yes, please describe:_____________________________________________________________

TRC/TCB/VA-VR Counselor:_____________________________________________________

I certify that the above information is correct to the best of my knowledge. I release the following information to the Student Support Services: transcripts, test scores, progress reports, income, diagnostic data, and other information from my records pertaining to program certification and support.

______________________________________________________________
Signature / Date