APPLICANT INFORMATION
* 1. First Name:
* 2. Last Name:
3. Middle Initial:
4. Maiden, Preferred, or Other Name:
5. Gender
Male
Female
* 6. Date of Birth:
7. Email Address:
* 8. Mailing Address
* 9. City
* 10. State
* 11. Zip Code:
12. Telephone:
13. Cell:
14. Work:
15. Do you identify yourself as Hispanic or Latino?
Yes
No
16. If no, check all that apply:
American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
* 17. Are you a U.S. citizen?
Yes
No
18. If not, are you an eligible non-citizen?
Yes
No
19. Alien Registration Number (A-Number)
* 20. Are you a veteran of the Armed Forces of the United States?
Yes
No
21. 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)
Yes
No
22. Is your spouse active duty?
Yes
No
23. Do you have a parent or guardian who is active duty?
Yes
No
24. Are you currently unemployed?
Yes
No
25. Have you filed a FAFSA (Free Application for Federal Student Aid) this year?
Yes
No
26. If yes, what date?
27. Have you applied to college this year?
Yes
No
28. If yes, please list the college name and your application date:
29. Are you a Worthington Scholar?
Yes
No
INCOME INFORMATION
* 30. 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.)
I do not file $0 - $23,475 $23,476 - $31,725 $31,726 - $39,975 $39,976 - $48,225 $48,226 - $56,475 $56,476 - $64,725 $64,726 - $72,975 $72,976 - $81,225 More than $81,226
* 31. Including yourself, what is the number of family members in your home?
32. Are you currently receiving TANF (Temporary Assistance for Needy Families)?
Yes
No
33. Are you currently receiving SNAP (Supplementary Nutrition Assistance Program)?
Yes
No
EDUCATIONAL INFORMATION
34. High School Information:
35. If you have a GED / HiSET, state and year received:
36. If you attended college, when and where?
37. If you attended college, did you take out a loan?
Yes
No
38. 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
* 39. What was the highest level of education completed by either of your parents before you were age 18?
Some High School High School or equivalent Some College (did not complete a degree) 2 Year College 4 Year College (Bachelor's Degree or higher) Other
If Other, please specify:
SUPPLEMENTARY INFORMATION FOR PARTICIPANTS UNDER THE AGE OF 24
40. Are you married?
Yes
No
41. Do you have any children for whom you are providing at least half their support?
Yes
No
42. Within the last year, have you been or were you at risk of being homeless?
Yes
No
43. 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?
Yes
No
FUTURE GOALS
44. What are your career plans?
* 45. What type of postsecondary degree is your goal (check all that apply):
Certificate (1-2 year) Associate (2 year) Bachelor (4 year) Advanced Degree
* 46. 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?
47. Do you have any questions that you'd like us to answer?
48. How did you learn about MEOC?
49. 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.
Click the button below to submit this application.
