Application

Thank you for your interest in Phillips Community College of the University of Arkansas TRIO Students Support Services program. Student Support Services is a federally funded TRIO program under the U.S. Department of Education that aids students in graduating from college. Please complete the application and submit the required documentation to determine eligibility. If you need assistance please contact us at 870-338-6474 ext 1175.

APPLICATION FOR SERVICES

GENERAL INFORMATION:

First Name *

Middle Name

Last Name *

Address *

City *

State *

Zip Code *

Date of Birth *

Cell Phone Number *

Home Phone *

Email Address *

Gender *

Race, American Indian or Alaskan Native *

Race, Asian *

Race, Black or African American *

Race, Hawaiian or other Native to Pacific Island *

Race, Hispanic *

Race, White *

Marital Status *

ELGIBILITY INFORMATION:

Are you a U.S. Citizen or Permanent Resident? *

Have you applied for or you receiving student financial aid? *

Does your mother have a 4-year college degree (Bachelor's)? *

Does your father have a 4-year college degree (Bachelor's)? *

Please check this box if you have a documented disability on file with the Disability Services office at PCCUA.

What is your current GPA? *

As of today, how many academic hours have you completed? *

ACADEMIC INFORMATION:

How many hours are you enrolled in this semester? *

What type of degree do you plan on getting from PCCUA? *

What is your major? *

Do you plan to transfer to a 4-year college or university? *

If yes, what college are you planning to transfer to?

What is your college classification? *

Where did you attend High School? (Name & Location)

When did you graduate high school or completed your GED? Please list which one applies and the year. *

Have you participated in any other TRIO Programs?

You are agreeing to abide by each of the following (Please read each statement carefully and click the checkbox to indicate that you agree.)

Agree to attend class regularly and sign-in to my online classes regularly.

See your SSS mentor at least once per month during the fall and spring semesters and upon request by an agreed-upon method (phone, in-person, text, email.)

Participate in SSS activities and workshops virtually or in-person.

Inform your SSS mentor of any difficulties you might be having that have the potential to impact your academic goals negatively.

Be actively involved in your education

SIGN & SUBMIT:

Terms of Submission:
By submitting this application, you acknowledge that all of the above information is correct and accurate to the best of your understanding.

Applicant Signiture *

Please select a signature verification type.