TRiO
Alabama A&M University
Student
Support Services
“Where Graduation is more than a Dream...It’s a Reality.”
TRiO-Student Support Services Alabama A&M University  211 Thomas Hall  Normal, Alabama 35762
100% Federally Funded Program by the "U.S. Department Education" INFORMATION DATA SHEET 2015-16
FOR OFFICE USE ONLY:
Date Received:
__________________
First Generation:  YES  NO
Low Income:
 YES  NO
Accepted:
 YES  NO
Date: _______________
TRiO - Student Support Services
PROGRAM APPLICATION
(256) 372-4710 office
(256) 372-5663 fax
STUDENT INFORMATION (Please Print)
LEGAL NAME:
LAST
FIRST
STUDENT ID#:
MIDDLE
A __ __ __ __ __ __ __ __
SOCIAL SECURITY #:
GENDER:
 Male
___ ___ ___ - ___ ___ - ___ ___ ___ ___
DATE OF BIRTH:
 Female
___ ___ / ___ ___ / ___ ___ ___ ___
LOCAL ADDRESS:
CITY/STATE
ZIP CODE
PERMANENT ADDRESS:
CITY/STATE
ZIP CODE
TELEPHONE NUMBER: (
) _______________________________
CELL (
BULLDOG EMAIL ADDRESS:
) ________________________________________
SECONDARY EMAIL ADDRESS:
FACEBOOK USERNAME:
TWITTER USERNAME:
INSTAGRAM USERNAME:
ETHNICITY: (CHECK ONE ONLY)
 American Indian/Alaska Native

Asian
 Black/African American
 Hispanic/Latino

White
 Native Hawaiian/Pacific Islander
 No Response/Unknown
CITIZENSHIP: (CHECK ONLY ONE)
ARE YOU A U.S. CITIZEN?
HAVE YOU PARTICIPATED IN ANY OF THE TRiO PROGRAMS
LISTED BELOW: (CHECK ALL THAT APPLY)
 YES
 NO
 EOC
 Student Support Services
 Talent Search
 Upward Bound
UNIVERSITY STATUS
DATE OF ENROLLMENT:
CURRENT GPA:
COLLEGE/ MAJOR/MINOR:
CLASSIFICATION:
 FRESHMAN
 SOPHOMORE
 JUNIOR
 SENIOR
ARE YOU A TRANSFER STUDENT?
 YES _______________________________________________
 NO
PRINT NAME OF INSTITUTION
100% Federally Funded Program by the "U.S. Department Education" INFORMATION DATA SHEET 2015-16
Name: __________________________
Banner ID: A_____________________
DISABILITY & VETERAN VERIFICATION
DO YOU HAVE A DOCUMENTED DISABILITY?
 YES
 NO
IF YES, CAN YOU PROVIDE DOCUMENTATION?
Documentation must be provided by a Licensed Professional or State Rehabilitation Office
 YES
ARE YOU A VETERAN?
 NO
HOUSEHOLD INFORMATION & ELIGIBILITY CRITERIA
PLEASE INDICATE WITH WHOM THE STUDENT REGULARLY LIVES
NAME
FIRST
MI
CONTACT INFORMATION
LAST
CELL:
RELATIONSHIP TO STUDENT
 LEGAL PARENT(s)
 LEGAL GUARDIAN(s)
 FOSTER PARENT(s)
OTHER
EMAIL:
(SPECIFY) _____________________
DOES EITHER PARENT/GUARDIAN HAVE A FOUR YEAR DEGREE?
 YES
 NO
MOTHER
________________________________________________________ (PRINT NAME OF COLLEGE/UNIVERSITY)
FATHER
________________________________________________________ (PRINT NAME OF COLLEGE/UNIVERSITY)
2014 HOUSEHOULD INCOME INFORMATION
(FOR HOUSEHOLD IN WHICH STUDENT REGULARLY LIVES)
ALL APPLICANTS MUST COMPLETE THIS SECTION, WHETHER YOU BELIEVE YOU QUALIFY AS LOW-INCOME OR NOT. THE FEDERAL
INCOME LEVEL TO DETERMINE ELIGIBILITY IS ATTACHED ON THE BACK OF THIS PAGE. VERIFICATION OF FINANCIAL ELIGIBILITY
FOR THE PROGRAM MUST BE PROVIDED (I.E. - INCOME TAX RETURN, SOCIAL SECURITY)
FOR FINANCIAL AID PURPOSES, ARE YOU CONSIDERED?
 INDEPENDENT STUDENT
 DEPENDENT STUDENT
(PARENT(S) CLAIM YOU ON THEIR TAX RETURN)
IF DEPENDENT, DID YOUR PARENTS/ GUARDIANS FILE TAXES
LAST YEAR?
 YES - ( PLEASE ATTACH COPY OF PARENT/GUARDIAN RETURN)
 NO
HAVE YOU APPLIED FOR FINANCIAL AID?
 YES
 NO
IF INDEPENDENT, DID YOU FILE TAXES LAST YEAR?
 YES - ( PLEASE ATTACH COPY OF YOUR RETURN)
 NO
NUMBER IN HOUSEHOLD CLAIMED ON YOUR PARENT’S
INCOME TAX RETURN?
______________
HAVE YOU RECEIVED YOUR FINANCIAL AID AWARD?
 YES
 NO
IF YES, DID YOU RECEIVE PELL GRANT?
 YES
 NO
100% Federally Funded Program by the "U.S. Department Education" INFORMATION DATA SHEET 2015-16
2014 FERERAL LOW-INCOME LEVELS
(Effective January 28, 2015 until further notice)
Size of Family Unit
48 Contiguous States,
D.C., and Outlying Jurisdictions
Alaska
Hawaii
1
$17,655
$22,080
$20,325
2
$23,895
$29,880
$27,495
3
$30,135
$37,680
$34,665
4
$36,375
$45,480
$41,835
5
$42,615
$53,280
$49,005
6
$48,855
$61,080
$56,175
7
$55,095
$68,880
$63,345
8
$61,335
$76,680
$70,515
For family units with more than eight members, add the following amount for each additional family member:
$6,240 for the 48 contiguous states, the District of Columbia and outlying jurisdictions; $7,800 for Alaska;
and $7,170 for Hawaii.
The term "low-income individual" means an individual whose family's taxable income for the preceding year
did not exceed 150 percent of the poverty level amount.
The figures shown under family income represent amounts equal to 150 percent of the family income levels
established by the Census Bureau for determining poverty status. The poverty guidelines were published by
the U.S. Department of Health and Human Services in the Federal Register on January 22, 2015.
100% Federally Funded Program by the "U.S. Department Education" INFORMATION DATA SHEET 2015-16
Name: __________________________
Banner ID: A_____________________
PROGRAM PARTICIPATION REQUIREMENTS

INITIAL
Participant agrees to meet with SSS program specialist at least two (2) times per semester for academic advisement.
Participant agrees to attend mid-term evaluation session.
Participant agrees to attend the mandatory orientation and three (3) workshops per semester.
Participation agrees to participate in weekly tutoring and/or mentoring. (if applicable)
PARTICIPATION AGREEMENT & RELEASE OF INFORMATION
As a participant in the Alabama A&M University Student Support Services (SSS) Program, I am committed to my education.
To gain the full benefits of the SSS Program, I will make a commitment to my academic goals and the assistance provided. I
understand and will strive for 100% CLASS ATTENDANCE, 100% CLASS COMPLETION and A MINIMUM GRADE
POINT AVERAGE OF 2.0. I also understand the Alabama A&M University SSS program specialists will review data from my
application and interview to assist in assessing my academic and career planning needs. Therefore, all information used will be
kept strictly at the highest level of confidentiality. I give the SSS staff permission to inquire about my class attendance, class
work, tutoring sessions, and receive grade reports, and I give my instructors permission to release such information to SSS
when requested. The SSS staff will assist me in achieving my academic goals only if I uphold my responsibilities in accordance
with the SSS Needs Assessment. Should I not meet the requirements and fulfill my academic goals, it may result in serious
consequences regarding my continuation as a participant in the SSS program. _________ (Initial)
I authorize Student Support Services to gather information concerning all my academic progress (standardized test scores,
grade point average, earned credit, transcripts, tutoring, etc.) and financial aid status prior to my participation in SSS. I
understand that this information is used to help determine my eligibility for SSS and kept strictly confidential. I grant
permission for SSS to gather information for follow up whenever appropriate, including, but not limited to, progress to
graduate institutions. I am aware that my eligibility and financial aid status will be reported to the U.S. Department of
Education in accordance with the grant funding regulations. I certify that the information provided on this application is true
and complete to the best of my knowledge. I also agree to provide documentation upon request to verify the information
reported. _________ (Initial)
I hereby authorize the use of my photographic image in any and all publications, such as the monthly newsletter, newspaper
articles and campus-wide e-mail notices. I authorize Alabama A&M University to use my name, photo or information about me
in promotion of the college through radio, television, Facebook, Twitter, Instagram, or other materials. I understand that my
picture could come from a digital image such as my file or from photos taken on various field trips and social events.
_________ (Initial)
I am aware that personal information provided to Student Support Services will be protected under the Federal Education
Rights Privacy Act (FERPA) of 1974. No one will have access to the information unless they work with or for SSS, or are
specifically authorized by me to see the information. _________ (Initial)
SIGNITURE OF STUDENT: _______________________________________
DATE: _____________________
SSS PROGRAM STAFF: __________________________________________
DATE: _____________________
100% Federally Funded Program by the "U.S. Department Education" INFORMATION DATA SHEET 2015-16
Name: __________________________
Banner ID: A_____________________
BIOGRAPHICAL DATA
PLEASE PRINT LEGIBALY
BRIEFLY TELL US ABOUT YOURSELF IN THE SPACE PROVIDED
DESCRIBE ANY ACADEMIC CHALLENGES OR CONCERNS
LIST YOUR EDUCATIONAL AND CAREER GOALS
100% Federally Funded Program by the "U.S. Department Education" INFORMATION DATA SHEET 2015-16