McNair Scholars Program Eligibility Form

I am a U.S. citizen

Yes No
I am a Permanent Resident.

Yes No
I am a member of a racial or ethnic group that is underrepresented in graduate education (American Indian, Alaska Native, Black or African American, Hispanic or Latino/a, Native Hawaiian or Native Pacific Islander).

Yes No
I am a first–generation college student (neither of my parents earned a 4- year degree).

Yes No
I meet the Federal TRIO Programs low income guidelines (my family’s taxable income is at or below the limits in the table below).

Yes No

Federal TRIO Programs Current Year Low-Income Levels: Taxable Income Effective January 15, 2020 until further notice

Size of Family Unit	48 Contiguous States, D.C., and Outlying Jurisdictions	Alaska	Hawaii
1	$19,140	$23,925	$22,020
2	$25,860	$32,325	$29,745
3	$32,580	$40,725	$37,470
4	$39,300	$49,125	$45,125
5	$46,020	$57,525	$52,920
6	$52,740	$65,925	$60,645
7	$59,460	$74,325	$68,370
8	$66,180	$82,725	$76,095

For family units with more than eight members, add the following amount for each additional family member: $6,270 for the 48 contiguous states, the District of Columbia, and outlying jurisdictions; $7,845 for Alaska; and $7,215 for Hawaii.

By signing below, I certify that the information above is true and correct to the best of my knowledge.

Name *

First Name Last Name
Signature *

Clear
Date
Applicant Information
RIC ID Number
Name

First Name Middle Initial Last Name
Gender

Male Female N/A
Preferred Name
Date of Birth
Pronouns (check all that apply)

She/her/hers He/him/his They/them/theirs
Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Contact Phone

Area Code Phone Number
Personal Email
example@example.com
Race/Ethnicity

American Indian or Alaska Native Asian Black or African American Hispanic or Latino/a Native Hawaiian or Pacific Islander White
Educational Information
Majors(s)
Minor(s)
Total Credit Hours Earned
Credits Registered
Cumulative GPA
Expected Graduation Date (month and year)
What is the highest degree you seek to obtain?

Master’s Ed.D. Ph.D.
Did you transfer to RIC from a community college or another university?

Yes No
What school and what month and year?
Family Information

Highest Educational Level Completed by Parents or Legal Guardian
Legal Guardian 1

Less than High School High School Some College Bachelor’s Degree Graduate N/A
Legal Guardian 2

Less than High School High School Some College Bachelor’s Degree Graduate N/A
Income Verification

List the number of individuals living in your family household including yourself:
List the number of individuals living in your family household including yourself
Are you:

Dependent (you receive support from parent(s)/Legal guardian) Independent (you are not dependent on any financial support from legal guardian/parent(s))
What was their TAXABLE income?
Parent Signature *

Clear
Did you file a federal income tax return for last year?

Yes No
What was your TAXABLE income?
Student Signature *

Clear
Release of Information Signature Form
RIC ID Number
Name

First Name Last Name
This release form enables the RIC McNair Scholars Program to obtain the following information for the purpose of determining eligibility, developing education plans, and collecting program statistics:
- College/university admission & enrollment
- Grade reports/transcripts
- Financial aid reports and information regarding scholarships, fellowships, and other awards received
- U.S. residency status
- Current contact information (address, phone number, email address)
- Past TRIO participation
Aspects of this information and the nature of your participation in the McNair Scholars Program may be shared with the U.S. Department of Education, the McNair Program Advisory Committee and RIC personnel in accordance with federal regulations and RIC policy.

My signature below indicates that I hereby authorize the release of my academic, personal, and medical (when necessary) records to the McNair Program at Rhode Island College for the purpose of serving my needs and meeting its federal regulations. I also hereby attest that, to the best of my knowledge, the information given in this application is true, complete, and accurate.
Signature *

Clear
Date *
Should be Empty:

Applicant Information

Educational Information

Family Information

Income Verification

Release of Information Signature Form