Updated PSE Form

Updated PSE Form
Initial Information

Student Support Services is a federally funded TRiO program that provides services to students who demonstrate an academic need and meet one or more of the following requirements: a first generation college student, meet income guidelines, and/or have a documented disability. 

APPLICANTS MUST COMPLETE ENTIRE APPLICATION IN ORDER TO BE PROCESSED

Date:
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ID #:
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Initial semester in which you are requesting services:
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Part 1: Student Profile
First Name:
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Middle Initial:
Last Name:
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Birth Date:
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Local Address:
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City:
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State:
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Zip:
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Local Phone:
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Cell Phone/ Other:
Dorm Student:

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Dorm Name & Number:
Gender:

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Are you Hispanic/Latino?

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Ethnic Origin: (Select at least ONE that applies)




School E-mail:
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Other E-mail:
Classification:


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Enrollment:
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Are you a transfer student?

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If Yes, from where?
Are you a veteran of the United States Armed Forces?

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Are you a ward of the court or homeless?

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Are you currently employed?

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Are you currently on academic probation?

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Have you ever been on academic suspension from OLLU?

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If yes, when?
Are you registered for any intensive courses (Math 1301 INT, MATH 1304 INT or ENGL 1313 INT)?

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Part 2: Permanent Address (if different)
Permanent Address:
City:
State:
Zip:
May we send mail to this address?

Permanent Telephone:
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Part 3:
Citizenship

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If other than United States, indicate visa type or Resident Alien No.
If you selected other, please attach a copy of your Permanent Resident Card to part 6.
Marital Status:
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Referred to Student Support Services by:
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If Other Please specify:
Please select if you have ever been a participant in any of the following TRiO programs:



At which high school or college did you participate in any of the above programs:
Part 4: Additional Information
Major(s):
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Minor(s):
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College Hours Completed:
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Expected date of graduation:
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Explain in detail your plans after graduation (Graduate School, Employement, Career goals/ aspirations, additional degrees you would like to attain, etc.)
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Why are you interested in being a Student Support Services participant?
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What classes/ subjects do you like or feel best about? Why?
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What classes/ subjects do you find difficult or concern you most? Why?
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Are you involved in any extracurricular activities? Please List.
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How can Student Support Services help you complete your degree? (Please check all that apply.)











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Educational Motivational/Academic Concerns (Check all that apply.)



















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Part 5: Eligibility Information
Highest Education Level of Your Mother:
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If Other please specify:
Highest Education Level of Your Father:
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If Other Please Specify:
Which type of financial aid are you receiving for the current year? (Please check all that apply.)
















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Do your parents claim you as an exemption on their income tax return?

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Total number of people in family household:
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Please indicated your family's Annual Taxable* Income:
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(*Please note that you can find the Annual Taxable Income from last year's tax return on: Line 43 - Form 1040; Line 27 - Form 1040A; Line 6 - Form 1040EZ. Do not use the amount listed for Adjusted Gross Income on your income tax form. NOTE: Additional documentation will be required).
Do you have a documented disability?:

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If yes, what type of disability do you have?
Is your documentation on file with:

(If you have a documented disability but have not yet filed your documentation with either of these offices, you will need to do so before we can verify your eligibility for services based on this requirement.)
Part 6:
Click the link below and print out.
Part 6 of Application
Sign and return this along with any other documentation to the TRiO office Located in Worden Building Room 25.