Educational Opportunity Center Intake

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To enable us to properly assist you, please enter all requested information.

First Name: *

Last Name: *

M Initial:

Address: *

City: *

State: *

Zip Code: *

Preferred Phone: *

Alternate Phone:

Tri-C S-Number:

Email: *

Gender: *

MaleFemale

Age: *

Ethnicity (Hispanic/Latino)?: *

YesNo

Race (Check all that apply): *

U.S. Citizen or Permanent Resident: *

YesNo

Veteran:

YesNo

I have a High School Diploma or GED:

YesNo

I attended College in the past:

YesNo

I have a 4-year Degree:

YesNo

I have a certificate or 2-year College Degree:

YesNo

I am currently enrolled in:

GED/ABLE Classes/ Non-Credit ClassesCollege Classes

I am interested in obtaining information and/or assistance regarding:

GED Enrollment or Testing
Short-Term/Vocational Certificate
2-Year Associate Degree
4-Year Bachelor Degree
Other

Have either of your parents/guardians completed a bachelor's degree (4-year):

YesNo

Household Taxable Income Last Year:

I authorize the exchange of information between the Educational Opportunity Center (EOC) and other agencies, as necessary to assist me in achieving my educational goals. By signing and submitting this application, I certify that the information provided is complete and correct in every respect.

Signature (Type Name): *

Date: *

Time: *

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