Student Support Services Application Return this application to: Student Support Services OMNI State College PO Box 443086 Some Place, USA 12345 Part I: Applicant Information Last Name Name Middle Name Social Security # OMNI Student ID Date of Birth Address Local PO Box Local City, State, Zip Permanent Address Permanent PO Box Permanent City, Zip Local Phone # Cell Phone # Emergency Phone # School Email Address Other Email Address Gender:  Female  Male Ethnic Heritage:  African American  Caucasian  American Indian  American  Chicano/a Latino/a  Alaskan Native  Other, please specify: Citizenship:  US Citizen  Permanent Resident #: Part II: Academic Information Are you registered for classes at OMNI College?  Yes  No Are you a transfer student?  Yes  No Major Minor Academic Advisor Year in School:  Sophomore  Junior  Senior Year you plan to graduate: OMNI Cum GPA: Do you plan to receive a degree?  Yes  No If yes, what degree? Where did you go to high school? Did you graduate?  Yes  No If yes, what year? If no, did you receive a GED?  Yes  No If yes, what year? Have you participated in any other TRIO program?  Yes  No If yes, which program(s)?  UB  TS  Other SSS When? Referred to SSS by:
How can we help you complete this degree? Check all that apply. Academic Skills  Time Management  Study Skills  Test Taking  Reading Speed  Reading comprehension  Writing  Research Writing  Critical Thinking  Vocabulary  Organization  Proofreading  Spelling  Note Taking  Basic Computer Skills  Basic Math  Finite Math  Algebra  Test Anxiety  Typing  Peer or Group Tutoring  Learning Strategies  Other Career Development Skills  Interest Testing  Career Choice  Choosing a Major  Career Guidance  Academic Advising  Resume Design  Interviewing  Job Search  Career Information  Other Personal Assistance  Peer Mentoring  Goals/Decision Making  Problem Solving  Financial Aid Advising  Can you think of anything that might keep you from completing your degree, such as family, grades, social life, money, self-motivation, career decision, other? Please explain. Part III: Family Information The information below, which must be provided by all applicants, is used to determine applicant‟s eligibility for the Student Support Services Project and will be treated confidentially. Last year‟s Income Tax Return must be returned along with the application. Name of Mother/Guardian Highest Level of Schooling Completed:  Elementary Level (Grade 1-6)  Secondary Level (Grade 7-12)  Some College, No Degree  Associate‟s Degree  Bachelor‟s Degree  Master‟s Degree Name of Father/Guardian Highest Level of Schooling Completed:  Elementary Level (Grade 1-6)  Secondary Level (Grade 7-12)  Some College, No Degree  Associate‟s Degree  Bachelor‟s Degree  Master‟s Degree
Student Support Services Student Eligibility and Certification Summary Grant Year: Student Name: Social Security #: Classification: Enrolled at Institution?  Yes  No Sophomore Junior Senior Completed credit hours Eligibility: First Generation College Student?  Yes  No Low Income Verified Financial Aid Verified Family Size Taxable Family Income Document Received for Verification Needs survey and determination of academic need:  Check if complete Comments: The signing of this form is to certify that all documents have been reviewed and eligibility has been determined and approved by the proceeding initials and the following signature of a different staff member. SSS Member Signature Date