IDAHO  EDUCATIONAL  OPPORTUNITY  CENTER
(Confidential Student Application Form)

Last        First           Mid

Date       

Address   Address2   
City        State       

Zip code

SSN #     E-mail        
Phone     Age  *      

Sex       M       F
Birthdate Birth Place

 
Are  You  A  United  States  Citizen?

Yes    No , I am a legal resident.

A#

Are  You  A  Veteran? Yes    No

Marital Status
Do you have a documented handicap? Yes    No

How  do  you  describe  yourself? American Indian / Alaskan Native

                                                            

Asian

Black / African

Hispanic / Latino

White

More than one race
What is your current level
of Education?		 Please Check all that apply
Yes,  Still enrolled in School High School  Grade
Yes,  Received H. S. Diploma Grad. Year   State
No,  never earned a H. S. Diploma
Yes,  Received G.E.D. Yes,  Received H. S. Equivalency AAS or 2yr done
No, no Vocational, 2yr or 4yr Started College but quit
Enrolled in Vocational, 2yr or 4yr Institute
year 1                year 2 year 3                  year 4 year 5

Other    
 

 

How did you learn of E O C ?              

Did  either  of  your  parents (Birth or Adoptive) ,  receive  a  four  year degree?     No    Yes

 

p 2


Total number of people currently living in your home

1 2 3 4 5 6 7 8 9 10 or more

                                                                                                                      
 

What  was  your  family's  annual  taxable  income  for  last  year?  
  $ 0 - $ 12,885  
  $ 12,886  -  $ 17,415  
  $ 17,416  -  $ 21,945  
  $ 21,946  -  $ 26,475  
  $ 26,476  -  $ 31,005  
  $ 31,006  -  $ 35,535  
  $ 35,536  -  $ 40,065  
  $ 40,066  -  $ 44,595  
 

Public assistance (welfare, social security, food  

    stamps, AFDC, etc.)  
  Other
     

(The U.S. Department of Education requires the Educational Opportunity Center give priority to low-income and first generation individuals.)
 Your signature below indicates that the information you have provide in this documentation
is accurate and verifiable .  All information will be kept confidential.

* Individuals 18 years and below must have the signature of a parent or legal guardian to
participate in EOC programs.

 




Signature of Prospective Participant                                                                                          Date                  



Signature of Parent or legal Guardian                                                                                       Date                  
(require for 18 years in age or below)
                                                               

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