For office use only:

Intro Meeting
Day/Date/Time:
Date Received/Staff Initials FG LI DI
❑ Ok for 1st mtg: Intake Meeting
Day/Date/Time:
❑ Has income docs
❑ Has DI docs or n/a st
1 call:
North Hennepin Community College ❑ Has test or waiver Advisor:
❑ Signed application 2nd call:

APPLICATION
Student Support Services/TRIO North Hennepin Community College
2nd Floor, Campus Center Rm 227 7411 85th Avenue North
Office: 763-424-0937 Fax: 763-493-0576 Brooklyn Park, MN 55445

Name Student ID#

Address City State Zip

Social Security Number* - - Date of Birth: / /

Cell Phone ( ) (text ok? Y N) Home Phone ( )

Email For Office Use Only:

ADEV 0163 55+ Y N

Please answer the following questions to be considered for NHCC’s SSS/TRIO Program.
1. Residency: ❑ U.S. Citizen ❑ Refugee ❑ Permanent Resident ❑ International Student (F-1 Visa) ENGL 0164 65+ Y N

2. Do either of your parents have a Bachelor Degree (4-year from a university or college) or higher? ❑ Yes ❑ No Math A 0165: 0-37= M801
EA 0166: 55-120= M900
3. Do you have a documented disability? ❑ Yes ❑ No (if yes, please attach a copy of your documentation) CL 0167: 0-35=M980*
ESOL 5005, Writing (1260)
4. Have you applied for financial aid? ❑ Yes ❑ No
4+
If no, do you plan to apply for financial aid? ❑ Yes ❑ No ESOL 0229, Reading (1230)
5. When do you plan to attend college? ❑ Day ❑ Evening ❑ Weekend ❑ Online (check all that apply) 108+

6. Have you been a student at NHCC before? ❑ Yes ❑ No ESOL 0231, Vocab (900)
65-114+
If yes, what semester and year did you begin?
ESOL 0232, Listening (980)
7. Do you already have a degree? ❑ No ❑ Yes, I have a 77-82+
❑ FG 3 ❑ DI 4
8. List any other colleges or universities that you have attended:
❑ LI 2 ❑ DIFG 4
❑ LIFG 1 ❑DILI 5
❑ Not Elig ❑ DILF 5
9. Have you ever participated in any other TRIO program such as Student Support Services, Upward ❑ 1st yr/never attended
Bound, Educational Talent Search or Educational Opportunity Center? ❑ Yes ❑ No❑ ❑ 1st yr/prior attendance
10. Have you ever participated in a program titled “College Possible”? ❑ Yes ❑ No❑ ❑ 2nd yr/sophomore
• If yes, are you currently an active participant? ❑ Yes ❑ No❑ ❑ Transfer

11. Do you plan to complete a degree at NHCC? ❑ Yes ❑ No

Continued on reverse side -
 12. Have you decided on a major or career focus? If yes, what?
13. Do you plan to transfer to a 4-year college or university? ❑ Yes ❑ No
14. How did you hear about NHCC’s TRIO program?
15. Have you been out of school for more than 5 years? ❑ Yes ❑ No
16. Do you need more information or help about any of the following?
❑ Information on transferring (13) ❑ Study skills (14)
❑ Choosing a major (13) ❑ Writing skills (14)
❑ Choosing a career (13) ❑ Math skills (14)
❑ Improving grades (15) ❑ Reading skills (14)
❑ Computer skills (14)

Federal regulations require that we collect and verify certain information about you, so before you return this application to SSS/TRIO,
please make sure that you complete the following:

❑ Sign and date the application.

❑ Attach a copy of your assessment test scores (Accuplacer).
❑ Attach a copy of your income documents:
Please attach a copy of your most recent tax return/s (1040, 1040A, or 1040EZ). If you are not self-supporting or independent
(according to FAFSA guidelines), please include your parent(s)/guardian(s) most recent tax return as well. We will not be able
to determine your eligibility without this information. If you have questions or this information is unavailable, please contact
us.
❑ Attach a copy of your disability documentation (if applicable).
❑ In the case of an emergency, please provide the name, address and phone of someone who can help us reach you:

Name/Relationship: Phone:

Address: Alternative Phone:

City, State, Zip

* DATA PRIVACY POLICY: NHCC SSS/TRiO is asking you to provide information which includes private information under state and federal law. In accordance with the Privacy Act of 1974 (Public
Law No. 93-579, 5 U.S.C. 552a), you are hereby notified that the Department of Education is authorized to collect information to implement the Student Support Services Program under Title IV
of the Higher Education Act of 1965, as amended (Pub. Law 102-325, Sec. 402D). In accordance with this authority, the Department receives and maintains personal information on
participants in the Student Support Services program. This information will be used to evaluate your application for admission into our program. Providing the information on this form,
including a social security number (SSN) is voluntary; failure to disclose a SSN will not result in the denial of any right, benefit or privilege to which the participant is entitled. However,
SSS/TRIO may not be able to consider your application if you do not provide sufficient information. The principal purpose for collecting this information is to administer the program, including
tracking and evaluating participant progress, and may be released to other Department officials in the performance of our official duties. Federal and state law authorizes release of private
information without your consent to: school officials who have legitimate educational interests in the information; the juvenile justice system, if you are a juvenile, and the information is
necessary, prior to adjudication, to determine the juvenile justice system’s ability to serve you; an alleged victim of sexual assault, if your parents claim you as a dependent student for tax
purposes; a court, grand jury, or state or federal agency, if the information is sought with a subpoena; appropriate persons in connection with an emergency, if necessary to protect your health
or safety of the health or safety of others; if required by court order, or permitted by other state or federal law.

I certify that I have read the above Data Privacy Policy and that the information I have provided on this application is
true and correct to the best of my knowledge.

Student Signature Date

If you need help filling out this form, ask in our office located in Campus Center RM 227. If you would like to receive this information in a different format, call 763-424-0555. North Hennepin Community College is a member of the Minnesota State Colleges and
Universities System. NHCC is an equal opportunity educator and employer. For disability accommodations, call 763-493-0555. Minnesota Relay users may call 1-800-627-3529. UPDATED ON 4/2015