APPLICATION 07-08
PERSONAL INFORMATION
Name: _______________________________________ GCC Student ID: ______________________
Date of Birth:
_________________________________ Social Security Number: _______ - _____ - ______
Current Address:
_____________________________________________________________________________
Number & Street
City, State, Zip
E-mail:__________________________________________ Home Phone: ( ) ______________________
Gender: ____ Male ____ Female Cell Phone: ( ) ______________________
Ethnicity: ____ Caucasian ____ Native American/Alaskan ____
Black
____
Hispanic ____ Asian/Pacific Islander ____
Other (fill in) _____________________
ELIGIBILILTY INFORMATION
Are you a
Do you have a documented disability? ______ YES ______ NO
If yes, are you willing to provide documentation? ______ YES ______ NO
Does your father/legal guardian have a four-year college
degree? ______
YES ______ NO
Does your mother/legal guardian have a four-year college
degree? ______ YES ______
NO
Were you claimed as a dependent on your parent’s 2006 tax
return? ______ YES ______ NO
If YES
Please enter your
parent’s 2006 TAXABLE INCOME
(Form 1040 line 43, 1040A line 27, 1040EZ line 6) $________________________
Please enter the
number of exemptions claimed in 2006
(Form 1040 line 6d, 1040A line 6d, 1040EZ
line 5) ________
If NO
Please enter your
2006 TAXABLE INCOME
(Form 1040 line 43, 1040A line 27, 1040EZ line 6) $________________________
Please enter the
number of exemptions claimed in 2006
(Form 1040 line 6d, 1040A line 6d, 1040EZ
line 5) ________
ACADEMIC NEED & SUPPORT
What is your current major? _____________________________________________________________
Who is your assigned advisor? _____________________________________________________________
Did you attend any other institution before coming to GCC? ______ YES ______ NO
What is your academic goal at this time?
____ Certificate and begin working
____ Certificate and continue education
____ Associates Degree and begin working
____ Associates Degree and transfer to a four-year
institution
The information on this application is used to determine
eligibility as defined by the Federal TRiO Program and will
be used to report to the Department of
Education. ALL INFORMATION AND
CORRESPONDENCE WILL
REMAIN CONFIDENTIAL. Please certify by signing below
that all information provided on this application is true
and correct to the best of your
knowledge.
Student Signature: __________________________________________________
Date: _______________
If you were claimed as a dependent on your parent’s
2006 income tax return, their signature is also required.
If your parents filed a joint return, only one of
their signatures is necessary.
Parent’s Signature:
__________________________________________________ Date: _______________
This section to be completed by SSS staff:
_______ $ ___________________ Applicant’s Taxable Income (2006)
|
Size of Family |
Maximum Taxable Income |
|
1 |
$ 15,315 |
|
2 |
$ 20,535 |
|
3 |
$ 25,755 |
|
4 |
$ 30,975 |
|
5 |
$ 36,195 |
|
6 |
$ 41,415 |
|
7 |
$ 46,635 |
|
8 |
$ 51,855 |
Math Placement___________
English Placement___________
H.S. GPA ____________
( ) Accepted: LI/FG
LI FG D
D/LI
( ) Denied (Indicate Reason Below)
Reason: ____________________________________________________________________
Signed:
_____________________________________________
Date: _________________