"A Beacon of Light Scholars Program"
TRiO Student Application
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Student ID#
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Are you a Transfer Student?
*
Yes
No
High School Graduate
*
Yes
No
Other (GED)
Sex
*
Male
Female
U.S. Citizen
*
Yes
No
Would you like to receive information about services for students with disabilities?
Yes
No
Have either of your parents/guardian earned a Bachelor's degree?
*
Yes
No
Have you applied for Financial Aid Assistance?
*
Yes
No
I affirm that the information I have provided is true and correct to the best of my knowledge. I also give permission for the Student Support Services program to receive and inquire about my transcript, grades, financial data recommendations, and evaluations in order to fulfill the requirements of the Student Support Services program.
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: