APPLICANT INFORMATION

* 1. First Name:

* 2. Last Name:

3. Middle Initial:

4. Maiden, Preferred, or Other Name:

* 5. Gender

6. Pronouns

7. Social Security Number:

* 8. Date of Birth:

9. Email Address:

* 10. Mailing Address

* 11. City

* 12. State

* 13. Zip Code:

14. Telephone:

15. Cell:

16. Work:

17. Do you identify yourself as Hispanic or Latino?

18. If no, check all that apply:

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

* 19. Are you a U.S. citizen?

20. If not, are you an eligible non-citizen?

21. Alien Registration Number (A-Number)

* 22. Are you a veteran of the Armed Forces of the United States?

23. Are you currently on active duty in the armed forces for other than training purposes? (Answer "no" if you are a National Guard or Reserves enlistee who is on active duty for state or training purposes)

24. Is your spouse active duty?

25. Do you have a parent or guardian who is active duty?

26. Are you currently unemployed?

27. Have you filed a FAFSA (Free Application for Federal Student Aid) this year?

28. If yes, what date?

29. Have you applied to college this year?

30. If yes, please list the college name and your application date:

College Name:

Application Date:

31. Are you a Worthington Scholar?

INCOME INFORMATION

* 32. Taxable Income Range (do NOT use total income, but after all deductions. This does not include child support, non-taxed social security benefits, state and federal assistance, and/or other non-taxed income. See line 15 of your 1040 federal income tax form.)

* 33. Including yourself, what is the number of family members in your home?

34. Are you currently receiving TANF (Temporary Assistance for Needy Families)?

35. Are you currently receiving SNAP (Supplementary Nutrition Assistance Program)?

EDUCATIONAL INFORMATION

36. High School Information:

Last grade of High School you completed:

Year:

Name of High School:

City of High School:

State of High School:

37. If you have a GED / HiSET, state and year received:

State:

Year:

38. If you attended college, when and where?

39. If you attended college, did you take out a loan?

40. If you participated in another TRIO program within the last year, please check all that apply:

Veterans Upward Bound
Educational Talent Search
Student Support Services
Upward Bound programs

* 41. What was the highest level of education completed by either of your parents before you were age 18?

If Other, please specify:

SUPPLEMENTARY INFORMATION FOR PARTICIPANTS UNDER THE AGE OF 24

42. Are you married?

43. Do you have any children for whom you are providing at least half their support?

44. Within the last year, have you been or were you at risk of being homeless?

45. At any time since you turned age 13, were both of your parents deceased, were you a dependent or ward of the court, were you an emancipated youth, or have you been in foster care?

FUTURE GOALS

46. What are your career plans?

* 47. What type of postsecondary degree is your goal (check all that apply):

Certificate (1-2 year)
Associate (2 year)
Bachelor (4 year)
Advanced Degree

* 48. What type of assistance do you need to meet your postsecondary goal (check all that apply):

College Admission
Financial Aid
College Transfer
Default Loan Counseling
Funding Opportunities
Career Counseling

QUESTIONS?

49. Do you have any questions that you'd like us to answer?

50. How did you learn about MEOC?

51. Referred to MEOC by:

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 authorize the use of my image and name in MEOC publications, editorials, advertisements, and media releases to the MEOC program and its affiliated organizations.

FERPA Statement

I/We authorize the release and exchange of student education records and transcripts to the MEOC program; I/We authorize the release and exchange of student financial aid information including FAFSA information from postsecondary institutions and the federal government to the MEOC program; I/We give permission to complete or correct the FAFSA over the phone when I am unable to be there in person; I/We understand that the information provided on this application will be held in confidence by the MEOC staff; I/We authorize MEOC to access all college records that may be stored in electronic and imaging systems in the University of Maine System & Community College System.

Applicant Signature

Use your mouse (or your finger or stylus, if on a mobile device) to sign this application in the space below. If you need to erase the signature and start over, click the Erase Applicant Signature button.

Parent or Guardian Signature (if needed)

Use your mouse (or your finger or stylus, if on a mobile device) to sign this application in the space below. If you need to erase the signature and start over, click the Erase Parent/Guardian Signature button.