Educational Opportunity Center Southwestern PA

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EOC-SWPA Application / Entry Into the Program

Name of Applicant:
E-Mail Address of Applicant:	* Required
Address:
County:
Phone:	* Required
Birth Date:
	Gender: Female Male
	Are you Hispanic/Latino?: Yes No
	Ethnic Background: American Indian Asian Hispanic White African American Native Hawaiian Bi-Racial
	Are you a U.S. Citizen?: Yes No
	Are you a Veteran?: Yes No
	Did either of your parents receive a 4-year degree?: Yes No
	Did you file an income tax return this year?: Yes No
	What is the size of your household:
	1 2 3 4 5	6 7 8 9+
	Please indicate your household taxable income range for last year: (You can find this information on your tax return 1040 line 39, 1040A line 24, 1040EZ line 6)
	$0 - $16,245 $16,245 - $21,855 $21,855 - $27,465 $27,465 - $33,075 $33,075 - $38,685 $38,685 - $44,295 $44,295 - $49,905 $49,905 - $55,515 $55,515 - +
	Educational Assessment: Did not finish High School* High School Diploma / GED Certificate or Diploma Program (college or technical program beyond HS) Less than 4 years of college (withdrawal) Associate Degree Bachelors Degree Masters Degree Ph. D.
	*Hightest grade completed: 9th 10th 11th
	Are you enrolled in a GED program?: Yes No
	GED Site: Start Date:
	Are you currently withdrawn from a community / technical college or university before receiving a degree or certificiate?: Yes No
	1. Have you applied to a postsecondary school or training program?: Yes No
	2. Are you Accepted into postsecondary school or training program?: Yes No
	3. Are you enrolled into postsecondary school or training program?: Yes No
	If yes to 1, 2, or 3 ... Name of Institution: Starting Date:
	Do you have a student loan?: Yes No
	If Yes, are you in loan default?: Yes No Unsure
	Previous postsecondary schools attended:
	Classes taken during high school and / or after high school: Basic Math Algebra Geometry Trigonometry + History English Foreign Language Science
	How can EOC assist you?
Upon submission, you will receive email confirmation.

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Web page last modified July 15, 2009