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Online EOC Application


EOC Online Application
Personal Demographic Information
*Last Name :
*First Name :
Middle Initial :
*Home Address :
Street :
City:
State:
Zip:
Country:



*Home Phone :
 ( )
Work/Cell Phone :
 ( ) -Extention
Email Address :
*Citizenship/Military Status :

1. U.S. Citizen
   Permanent Resident Alien
(Provide #: )
2. Veteran
*Age :
*Date of Birth :
 mm/dd/yyyy
*Gender :
 Male Female
*Race/Ethnicity :
Marital Status :

Single, never married
Seperated
Married
Widowed
Divorced
Employment Information :

Employed Full Time
Employed Part Time
Unemployed
Recieving Public Assistance
Income Eligibility Information
*Please provide last year's taxable income (your earnings from work).

If you did not file taxes. please enter "0"
 Taxable Income $
*Please indicate any other forms of family earnings

W2
Child Support
Social Security or Disability Benefits
Veterans' Payment
Unemployment Compensation
Other
None
*Total yearly amount from all sources:
 $
*Household size: Total number of persons living in the home, including yourself, who are supported by this income:
Income Eligibility Information
*Does either parent/guardian hold a 4-year (Bachelor) degree?

Neither
Mother/Guardian
Father/Guardian
Is English your native language? Yes No
*Current educational level:

Did not complete high school
     (Check highest grade completed)
          Below 8th grade 8th grade 9th grade
          10th grade        11th grade

Currently in a GED Program
     Anticipated completion:

High school or GED/HSED graduate
     When?

Attended a college or vocational/technical school,
     but did not graduate
     Institution:
     Date Graduated:

Currently enrolled in college
     Where?

College Graduate:
     AA Degree, Technical Diploma or Certificate
     Institution:
     Date Graduated:

If you plan to apply to college, which institution(s) are you considering? Institution:
Institution:
Institution:
Educational/Career Needs: I need assistance with the following (select all that apply)
GED/HS Diploma completion information
Financial aid information and/or application completion
College/Technical School admission information and/or       application completion
Career information or assessment
Other
Have you ever used EOC services? Yes No
How did you hear about the EOC? (Check all that apply)

Media
Family
Agency
Workshop Presentation
Other

Applicant Signature and Statement of Release of information and Confidentiality
I understand that to be admitted to the EOC program I must supply my social security number and income documentation, as required by the U.S. Department of Education.
I hereby consent to the release of my high school, GED/HSED, or college records (transcripts, financial aid, test scores, etc.) to the EOC program at the University of Wisconsin-Eau Claire, effective for the period of time that I am an active EOC participant and receiving services. Further, I authorize the EOC to share information useful to my educational and career planning, and to permit my photo or testimonial to be used to market the EOC program. I understand my personal data (i.e., name, address, SS#, phone number) will not be released. The above information is true and accurate to the best of my knowledge.
*Applicant's Name
*Date mm/dd/yyyy
Incomplete Applications Will NOT Be Processed
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