Dear Prospective Student:
Congratulations on your choice to continue your education at an institute of Higher
Learning! Please use this check-off sheet as a guide to make certain your file is complete
with our office before the specified deadline.
Please keep in contact with Utah State University-Uintah Basin Admissions and Financial
Aid Office to ensure your application is completed within a timely manner. In order to
avoid delay in the process, it may be necessary to check with their offices as well as ours
periodically. Utah State University-Uintah Basin have their own policies and deadlines to
meet, as well as the tribal Higher Education Department, so try to conform with these when
necessary.
Deadline Dates:
Fall Semester-September 15th
Spring Semester-January 15th.
DOCUMENTS REQUIRED FOR ALL STUDENTS:
Application-2 pages, Essay, Consent to Release Form, Signed Agreement
Official Certified Indian Blood Letter-Vital Statistic Office
Official High School Transcript or GED Certificate with test scores/Official College Transcript
Official letter of admission/ or documentation of enrollment with tuition and book amounts
Needs Analysis completed by the college
FAFSA Letter of Results
HIGHER EDUCATION OFFICE * P.O. BOX# 340*FORT DUCHESNE, UT 84026*725-4082*722-0811 (FAX)
UTE INDIAN TRIBE HIGHER EDUCATION
U.S.U. UINTAH BASIN PROGRAM
GRANT APPLICATION
Complete application packet includes: Policy and Procedures, Grant
Application, Consent to Release Information, Essay and Needs
Analysis. Incomplete applications will not be processed.
Personal Information
Name: ___________________________________________
SS#: ______/_______/______
Previous Name(s): _____________________________________________________________
Address:_____________________________________________________________________
City: ____________________________________State/ Zip Code:_______________________
E-Mail Address___________________________________________
Phone #: (
) _______________________
Tribe: _______________ FB#:___________
Marital Status:
 Never Married
 Married
Date of Birth: _____/_____/_____
Dependents:  None  1-3  4 or more
 Unmarried (Divorced or Widowed)
Department of Employment: ____________________________________
Name of Supervisor: ______________________________ Phone: _____________________
Status Information
Application Type:
Student Status:
 New
 Freshman
Are you a Veteran:  NO  YES
 Continuing
 Sophomore
 Transfer
 Junior
 Senior
 Returning
 Graduate
If yes, when/where: ___________________________
Do you have either of these (circle): High School Diploma / GED
Date Received: _________
Name of School where you received Diploma/GED: __________________________________
HIGHER EDUCATION OFFICE * P.O. BOX# 340*FORT DUCHESNE, UT 84026*725-4082*722-0811 (FAX)
School Information
 Fall 200 ____
Semester Attending (mark all that apply):
Type of Program/Degree enrolled in:
 A.S. (Associate of Science)
 B.A. (Bachelors)
 Two-Year Certificate
 Spring 200 ____
 A.A. (Associate of Arts)
 A.A.S. (Associate of Applied Science)
 M.A. (Masters)
 Other: ________________________
Major: ________________________________________
Minor: ______________________
Please list the school(s) you are considering to attend:
Name
Address
Phone Number
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
List any Colleges/Universities/Technical Schools attended in the past:
Name
Address
Year attended
Credits Earned
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
I hereby certify that the answers I have provided on this application are true and correct, and understand
that providing false information on this application may result in suspension from the program. I agree to
comply with all rules and regulations that are written in the Policy & Procedures with the Ute Indian Tribe
Higher Ed. Program. If for any reason I do not comply with these rules and regulations, I hereby agree to
accept the consequences that are given by either the Education Board and/or Higher Ed. Office. I
authorize the release of all academic records and information, such as: midterm reports, final grades and
transcripts, to be released from any school previously attended/currently attending to the Ute Tribe Higher
Ed. Office.
_______________________________________
_____________________________
Student Signature
Date
For Office Use Only
U.S.U. Grant Award Recipient:
Approved_______
Denied_______
Incomplete_______
____________________________________
Higher Ed. Counselor Aide Signature
_______________________
Date
_____________________________________
Education Director Signature
_______________________
Date
HIGHER EDUCATION OFFICE * P.O. BOX# 340*FORT DUCHESNE, UT 84026*725-4082*722-0811 (FAX)
CONSENT
TO
RELEASE INFORMATION
(STUDENT INFORMATION)
Name: __________________________________________________________
Social Security: ______/______/_______
DOB: ______/______/_______
Address: ________________________________________________________
Name:
Utah State University-Uintah Basin
Address:
810 East 200 North (124-9), Roosevelt, UT 84066
Phone:
435-722-2294
I, ______________________________, authorize the release of any Academic information or
records (such as: Midterm Reports, Final Grades, Class Schedules, Transcripts/or G.E.D. test
scores and any other Financial Information) to be released from the school named on this form to:
Ute Tribe Higher Education Office
P.O. Box 340
Fort Duchesne, Utah 84026
Phone (435) 722-2331
Fax (435) 722-0811
__________________________________
Name
_________________
Date
HIGHER EDUCATION OFFICE * P.O. BOX# 340*FORT DUCHESNE, UT 84026*725-4082*722-0811 (FAX)
UTE INDIAN TRIBE
HIGHER EDUCATION
UTAH STATE UNIVERSITY-UINTAH BASIN
ESSAY
What are your future goals and how will furthering your education assist you in achieving them?
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HIGHER EDUCATION OFFICE * P.O. BOX# 340*FORT DUCHESNE, UT 84026*725-4082*722-0811 (FAX)