Student Support Services Application Return this application to: Student Support Services OMNI State College PO Box 443086 Some Place, USA 12345 Part I: Applicant Information Last Name Name Middle Name Social Security # OMNI Student ID Date of Birth Address Local PO Box Local City, State, Zip Permanent Address Permanent PO Box Permanent City, Zip Local Phone # Cell Phone # Emergency Phone # School Email Address Other Email Address Gender: Female Male   Ethnic Heritage: African American Caucasian American Indian    American Chicano/a Latino/a Alaskan Native    Other, please specify:  Citizenship: US Citizen Permanent Resident #:   Part II: Academic Information Are you registered for classes at OMNI College? Yes No   Are you a transfer student? Yes No   Major Minor Academic Advisor Year in School: Sophomore Junior Senior    Year you plan to graduate: OMNI Cum GPA: Do you plan to receive a degree? Yes No If yes, what degree?   Where did you go to high school? Did you graduate? Yes No If yes, what year?   If no, did you receive a GED? Yes No If yes, what year?   Have you participated in any other TRIO program? Yes No   If yes, which program(s)? UB TS Other SSS    When? Referred to SSS by:
Student Support Services Application Return this application to: Student Support Services OMNI State College PO Box 443086 Some Place, USA 12345 Part I: Applicant Information Last Name Name Middle Name Social Security # OMNI Student ID Date of Birth Address Local PO Box Local City, State, Zip Permanent Address Permanent PO Box Permanent City, Zip Local Phone # Cell Phone # Emergency Phone # School Email Address Other Email Address Gender:  Female  Male Ethnic Heritage:  African American  Caucasian  American Indian  American  Chicano/a Latino/a  Alaskan Native  Other, please specify: Citizenship:  US Citizen  Permanent Resident #: Part II: Academic Information Are you registered for classes at OMNI College?  Yes  No Are you a transfer student?  Yes  No Major Minor Academic Advisor Year in School:  Sophomore  Junior  Senior Year you plan to graduate: OMNI Cum GPA: Do you plan to receive a degree?  Yes  No If yes, what degree? Where did you go to high school? Did you graduate?  Yes  No If yes, what year? If no, did you receive a GED?  Yes  No If yes, what year? Have you participated in any other TRIO program?  Yes  No If yes, which program(s)?  UB  TS  Other SSS When? Referred to SSS by:
ParticipantDocumentation.docx