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:
1. Name*

First NameLast Name
MI
Maiden Name/Other Name
Preferred Name
2. Social Security Number*
3. Address*

Street Address

Mailing Address

CityState / Province

Postal / Zip Code
County of Residency*
Contact Information
4. Mobile Number*
Telephone Number*
Work Number
Please check the box for the best contact number to reach you. Best times:*

AMPM
May we send text messages to your mobile number?*

YESNO
5. E mail Address*
example@example.com
6. Date of Birth*

MonthDayYear
Date
Age*
7. Gender*

MaleFemale
8. Race:*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhite or CaucasianOther
9. Are you a U.S. Citizen? If yes, skip to Question 10.*

YESNO
If not, are you a citizen of the Freely Associated States, including the Federated States of Micronesia and the republics of Palau and the Marshall Islands?

YESNO
If not, are you a eligible non-citizen?

YESNO
Alien Registration Number
Please attach proof of eligible non-citizenship. Acceptable documentation includes the following:
- Permanent resident card
- Passport
- Naturalization Certificate
- Citizenship Certificate
Browse Files

Cancelof
10. Do you have a disability?*

YESNO
11. Are you a Veteran?*

YESNO
If no, are you on active duty?

YESNO
Is your spouse active duty?

YESNO
Do you have a parent/legal guardian who is active duty?

YESNO
12. Are you a foster child?*

YESNO
13. Are you homeless?*

YESNO
EDUCATIONAL INFORMATION:
14. Are you currently in High School?*

YESNO
What grade are you currently in?*
Name of High School*
City and State of High School*
If you are currently in high school, skip to Question 18.
15. Last grade of school you completed
Type the year you last attended school
Name of High School
City and State of School
If you graduated high school, skip to Question 17.
16. Have you earned a GED or high school equivalent?

YESNO
Year received
State received
Test Site
If no, are you currently in an ABE/GED program?

YESNO
Program
Location
If you answered NO to either of the questions above, skip to Question 18.
17. Are you currently enrolled in a postsecondary institution, including junior college, university, or technical school?*

YESNO
If yes, tell us where.
If no, have you ever attended college?*

YESNO
If yes, when and where?
Did you graduate?

YESNO
Degree received
Do you have existing student loans?*

YESNO
18. If you have ever participated in another federal TRIO program, please check all that apply?

Educational Opportunity CenterRonald E. McNair Postbaccalaureate AchievementStudent Support ServicesTalent SearchUpward BoundUpward Bound Math-ScienceVeterans Upward Bound
19. Are you currently being served by another program?*

YESNO
If yes, which program(s)?
20. Did either of your parents, biological or adoptive ONLY, complete a Bachelor (4 year) Degree?*

YESNO
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).
Type a question*

I do not file$0 - $21,870$21,871 - $29,580$29,581 - 37,290$37,291- $45,000$45,001 - $52,710$52,711 - $60,420$60,421 - $68,130$68,131 - $75,840above $75,841
22. Number of people in your household, including yourself*
23. If 18 or older, are you currently employed? (If you are under 18, skip to Question 24.)

YESNO
FUTURE GOALS:
24. What are your career plans?
TELL US WHAT YOU NEED: Please check all that apply.*

ACT PrepACT Test VoucherPostsecondary Application AssistanceFinancial Aid Application Assistance (FAFSA)
If your family needs information about other economic programs in your community, briefly describe your needs. Please be as specific as possible. For example, you may be a new mother who needs help buying formula or would like parenting skills classes. The information contained in this application is confidential and will not be released without your permission.
How did you hear about DEOC?*

Current ParticipantFamily/FriendWebsiteFacebookDEOC Poster and/or FlyerABE/GED (If so, list the program name in the first blank following this question.)Agency Referral (If so, list the agency name in the second blank following this question.)Other (If so, list how you heard about the program in the third blank following this question.)
Program Name
Agency Name
Other
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.
Applicant Signature.*

Clear
Date

MonthDayYear
Date
If under 18, a parent’s or guardian’s signature is also required.
Parent/Guardian Signature.*

Clear
Date

MonthDayYear
Date
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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APPLICATION FOR SERVICES

APPLICANT INFORMATION:

Contact Information

EDUCATIONAL INFORMATION:

INCOME INFORMATION:

FUTURE GOALS:

Certification of Application and Information Release