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Online Application

Questions marked with a * are required

PART I: BASIC / PERSONAL INFORMATION

1.Social Security (Last 4 digits)

2.First Name

3.Middle Initial

4.Last Name

5.Address

6.City

7.State

8.Zip Code

9.Home Phone

10.Cell Phone

11.Date of Birth

12.Email Address

13.Gender

14.Ethnicity

PART II: ELIGIBILITY INFORMATION

15.U.S. Citizen?

Yes

16.Veteran?

Yes

17.Eligibility Requirements:

I have served at least 181 days of Active Duty.

I was a member of a reserve component of the Armed Forces, called to Active Duty for a period of more than thirty (30) days.

I was a member of a reserve component of the Armed Forces who served on Active Duty in support of a contingency operation on or after September 11, 2001.

18.Type of Discharge

19.Discharge Date

20.Please complete the chart below on your parents/guardians education:

	Mother Attended	Mother Completed	Father Attended	Father Completed
Elementary	Mother Attended	Mother Completed	Father Attended	Father Completed

High School	Mother Attended	Mother Completed	Father Attended	Father Completed

2-year College/University	Mother Attended	Mother Completed	Father Attended	Father Completed

4-year College/University	Mother Attended	Mother Completed	Father Attended	Father Completed

INCOME VERIFICATION

21.What was your Taxable Income (1040-line 43, 1040A-line 27, 1040EZ-line 6)? $

21.Number of Dependents (exemptions) claimed:

22.Filed taxes last year

Yes

23.Employment Status:

24. Do you have a documented service related disability?

Yes

PART III: EDUCATIONAL INFORMATION

25.Did you graduate from high school?

Yes

26.If you did graduated from high school, what year:

27. If you did not graduated from high school, did you receive a GED certificate?

Yes

28. If you received a GED, what year did you receive it?

29.Have you previously attended any post-secondary institution?

Yes

30.If you did attended any post-secondary institution, what year:

30.Name of institution:

31.Are you currently attending a post-secondary institution?

Yes

32.Name of institution:

How did you hear about this program? (Please check all that apply)

33.Did you hear us thru UT Arlington Website

Yes

34.Transition Assistance Program (TAP) - Year Completed

34.Social Media - Please Specify

34.Name of referrer - optional

34.Other - please specify

Failure to complete this portion will result in your application review being delayed.

35.By signing this I am certifying that this application information is complete and correct to the best of my knowledge. If my application is accepted, I agree to abide by the policies, rules, and regulations at the University of Texas at Arlington. Furthermore, I authorize the University of Texas at Arlington TRiO Pre-College Programs to verify the information I have provided. I understand that this information will be relied upon by officials of the University in determining my eligibility for the program and that submission of false information is grounds for denial of my application, withdrawal of an offer of acceptance, cancellation of enrollment, and/or any other appropriate disciplinary action. I also authorize the University of Texas at Arlington TRiO Pre-College Programs to electronically access my records possessed at The University of Texas at Arlington.

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