What is your full name?
Birthdate (mm/dd/yy):
Email Address:
What is your local address? List street, city, state, and zip code.
What is your home address? List street, city, state, and zip code.
Local/Primary Telephone Number:
Cell Phone Number:
Gender: Male
Female
College Status: Freshman
Sophomore
Other
Race/Ethnicity: White Yes
No
Race/Ethnicity: African American/Black Yes
No
Race/Ethnicity: Asian Yes
No
Race/Ethnicity: American Indian or Alaskan Native Yes
No
Race/Ethnicity: Native Hawaiian or Other Pacific Islander Yes
No
Are you of Hispanic or Latino descent? Yes
No
Are you an orphan, or are (were) you (until age 18) a ward/depdendent of the court? Yes
No
Are you an U.S. Citizen? Yes
No
Are you a veteran? Yes
No
Which of the following has been completed? Graduated from High School
Received GED
Please list the Month and Year of your High School graduation or completion of GED.
Were you a member of Upward Bound or Talent Search? Yes
No
Do you qualify for financial assistance (Pell Grants, loans, scholarships, etc.)? Yes
No
If you answered yes to the above question, please explain.
What is your marital status? Married
Divorced
Separated
Single
Are you a dependent or independent student? (Please use same status that was used for Financial Aid applications). Dependent
Independent
If you are a dependent student what was your parent's and your income for 2013?
If you are an independent student what was your income for 2013?
How many are in your family?
Do you have a physical or documented disability which requires special accomodations to help you succeed academically? Yes
No
If yes, specify below:
Has either of your parents/guardians received a bachelor's degree? Yes
No
Father's Education: (Select highest level completed)
Mother's Education: (Select highest level completed)
According to SSS CFR Part 646.7: First generation college student means 1. a student neither of whose natural/adoptive parents received a baccalaureate degree; 2. a student who, prior to the age of 18, regularly resided with & received support from only one parent & whose supporting parent did not receive a baccalaureate degree; or 3. an individual, prior to the age of 18, did not regularly reside with or receive support from a natural or an adoptive parent. Under this are you a first-generation student? Yes
No
In which of the areas listed below do you need assistance? Selecting a career
Study Skills
Writing
Computer Training
Learning about college majors
Note Taking
Math
Personal Counseling
Writing a resume
Test Taking and Memorizing
Managing Time
Job Interviewing
Reading
Financial
Other
What is your major?
Are you undecided on a major? Yes
No
Which degree are you seeking at NCMC?
Do you plan to transfer to another college?
Verification of Information: By checking this box I verify this information is accurate to the best of my knowledge.
I understand the SSS Program will use the data provided on this form to assist in assessing any academic and/or career planning needs & all of the information will be kept confidential. I release the following information to the SSS staff: high school transcripts, SAT/ACT/Compass scores, instructor evaluations, financial assistance award notices & income information, vocational rehab. records, disability services records & any other information from my academic records pertaining to enrollment in SSS. I certify the information on this application is true and correct to the best of my knowledge and by submitting this application I allow SSS program to use this information.

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