Purdue University North Central
TRiO Student Support Services Application

After completing this form, please use your browser's print button (or go to File>Print) to print a copy.  Then mail, fax, or bring your application in person to:

TRiO Student Support Services
Schwarz Hall, Room 38
Purdue University North Central
1401 South US Hwy 421
Westville, IN  46391
(219) 785-5312; 872-0527; 462-4197
Fax: (219) 785-5589

You may also save this page as a file and attach it to an email addressed to studentsupportservices@pnc.edu.

Name
  Last               First                    Middle Initial

Date of Birth
                       Month/Day/Year

Address
  Apt. #/Lot #         Street          City             State               Zip

Home Phone       Cell Phone

Has applicant previously participated in a TriO Program?   Yes    No   
If yes, indicate which program:   Student Support Services     Upward Bound       Talent Search

Is applicant a “Twenty-first Century Scholar”?   Yes   No

Is English applicant’s primary language?   Yes No                         Male    Female

Marital Status:   Single     Divorced     Married      Married but separated      Widowed

How many other people live in applicant’s home?    Are they:  Parents    Spouse    Children   Other

Who referred applicant to Student Support Services?

What is applicant’s career goal?

Eligibility Criteria
The following information is used to determine eligibility for sSs.
Failure to complete the following information may significantly delay review of your application.

  1. Has either parent/guardian earned a Bachelor’s degree?   Yes No

  1. Does applicant have a documented disability?   Yes No

           Disability will be verified with the Disability Services Coordinator.

  1. To verify income eligibility, please include with completed application a signed copy of last year’s Federal Income Tax Return. If applicant/parents do not file a tax return, sSs will provide an Income Verification form to be completed by applicant/parents.

I affirm that the information I have provided is true and correct to the best of my knowledge. I also give permission for the sSs Program Staff to receive my transcripts, grades, financial data, recommendations, progress reports and evaluations in order to fulfill the requirements of TRiO Student Support Services Program.

                                          
Initials:            Date:    

Supplemental Academic & Personal Needs

Name

Please check all services/workshops in which you are interested.
Advising
Academic Counseling/Degree Planning
Financial Aid Information
Career Counseling
Personal Counseling
Peer Mentoring
Other 		Workshops
Overcoming Test Anxiety
Memory Skills
Writing An Effective Paper
Time Management
Money Management
Note Taking Tips
Career Exploration
Other
Academic Support
Study Skills
Tutoring
Writing
Math/Level
Other 		Graduate School Planning
Graduate School Information
Graduate School Visits

 

Please explain why you have applied to become a participant in TRiO Student Support Services.

Please explain your commitment to your academic success.

TRiO Student Support Services is funded by the U. S. Department of Education, Department of TRiO Programs.
Acceptance into the program is contingent upon meeting eligibility criteria and space availability.
Purdue University is an Equal Opportunity/Affirmative Action University.