• APPLICATION FOR SERVICES

    APPLICATION FOR SERVICES

  • DEOC is a federally funded TRIO program designed to assist adults in accessing postsecondary education. DEOC is funded entirely by the United States Department of Education. All DEOC services are free. Please complete the information

  • APPLICANT INFORMATION:

  • Contact Information

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  • Please attach proof of eligible non-citizenship. Acceptable documentation includes the following:

    • Permanent resident card
    • Passport
    • Naturalization Certificate
    • Citizenship Certificate
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  • EDUCATIONAL INFORMATION:

  • If you are currently in high school, skip to Question 18.

  • If you graduated high school, skip to Question 17.

  • If you answered NO to either of the questions above, skip to Question 18.

  • INCOME INFORMATION:

  • 21. Taxable income range (required of all applicants) – Please check your total taxable income range. DO NOT use gross income. Taxable income is the amount after all deductions and exemptions. If you are unsure, please refer to your tax return information, or provide proof of your annual income. If you are under 18, please use the income of your parent(s).

  • FUTURE GOALS:

  • Certification of Application and Information Release

  • I/We certify that the information provided on the application is true and correct to the best of my/our knowledge; I/We further understand that the completion of this application does not guarantee acceptance into the Delta Educational Opportunity CenterDEOC) program.

    I/We authorize the use of my image and name in DEOC publications, editorials, advertisements, and media releases to the DEOC program and its affiliated organizations; I/We understand that if I need accommodation for a disability to participate in DEOC, or any of its scheduled activities, I/we must contact the Director of the Delta Educational Opportunity Center at 662.846.4337 at least working days prior to the activity.

    I/We will make every effort to provide DEOC with any requested documentation needed to evaluate/track/report academic progress.

    Student information is confidential and protected by the Family Educational Rights & Privacy Act (FERPA We cannot release or obtain certain information without your written permission. I/We authorize DEOC to request, receive, and release any academic and financial secondary and/or postsecondary information to assist with services needed.

    I/We further authorize DEOC to communicate verbally or otherwise with campus staff and faculty and/or offcampus professionals on my behalf to assist with services needed.

    My/Our consent will remain in effect until I/werevoke this authorization, in writing, with the DEOC office.

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  • If under 18, a parent’s or guardian’s signature is also required.

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  • MAIL THIS FORM TO:  Delta Educational Opportunity Center - CCED, DSU Box 3134, Cleveland, MS 38733; OR DELIVER THIS FORM TO: Center for Community & Economic Development, 1417 College Street, Cleveland, MS 38733

    For questions, contact us at 662.846.4335 or e-mail deoc@deltastate.edu.

    Title VI of the Civil Rights Act of 1964 states that no person in the United States shall, on the grounds of race, color, or national origin, be excused from participation in, be denied benefits of, or otherwise be subjected to discrimination under any programs or activities receiving federal financial assistance. Delta EOC operates in compliance with this law.

    In accordance with Title IX, Delta State University is committed to maintaining a learning and working environment free from sexual and gender-based discrimination, harassment, sexual assault, sexual exploitation, sexual intimidation, stalking, dating violence, domestic violence, or any other behavior that is non-consensual or has the purpose or effect of coercing a person or persons. For questions or concerns about Title IX, please visit www.deltastate.edu/titleix or contact Aja Rodriguez, Title IX Coordinator at (662) 846-4159 or email titleix@deltastate.edu.

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