Submit Your Application

Thank you for your interest in the EOC program at the University of Arkansas Rich Mountain! Please complete this application as thoroughly as possible. You cannot save and restart this application. You may want to review the included items, take some time to gather the required documents, and then return to submit your application. If you have any questions, please call our office at (479) 394-7622 extensions 1644, 1643, 4010, 4011.

Participant Application

Social Security Number

Gender

First Name *

Last Name *

Middle Name

Date of Birth *

Current Age

Address *

Address 2

City *

State *

ZIP Code *

Home Phone

Cell Phone

Email *

Additional Info:

Which High School do/did you attend?

Are you Hispanic or Latino?

Ethnicity *

Citizenship *

If you are not a US Citizen, but you are a Permanent Resident, enter your RA#

Current Grade Level *

What is your marital status (Not your Parents)?

Do you have children who live with you and receive more than half of their support from you? *

Since you turned 13, were both your parents deceased, were you in foster care, or a ward of court?

Veteran

Are you an emancipated minor or in legal guardianship? *

Are you connected to the Military?

Are you an unaccompanied homeless youth or at risk of being homeless? *

Family Size and Income Information:

Parents Educational Level *

How many people are in your family? *

What is the Adjusted Gross Income Range of your family (Most recent 1040 Tax Return line 11)?

Your Family's Taxable Income Range (Most Recent Tax Return line 15)

Most Recent IRS 1040

If you live with your parents, which Standard Deduction did your Parents Use when filing their Tax Return (Most recent 1040 Line 12)? If Independent, which Standard Deduction did you use when filing your Tax Return (Most recent 1040 Line 12)?

AUTHORIZATION AND RELEASE

My electronic signature below certifies that the information provided in this application is correct to the best of my knowledge. I attest that I have requested assistance with admissions/financial aid and that I have the desire to pursue a program of post-secondary education (HEA, SEC 402F & 34CFR644.3 (a)(3). I further certify that I am in need of academic support to successfully pursue/complete this program of post-secondary education. I grant the TRiO Programs (Educational Opportunity Center) permission to send for/receive copies of transcripts, financial aid information/awards, student aid reports, test scores, and other relevant information necessary for permission in the program and allow state/federal agencies permission to release any/all income information.

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Signature: (Type in your full name)

I agree to the terms included.

I certify that the income information presented in the application is accurate to the best of my knowledge:

Parent or Guardian Signature: