ACT 101 Fall 2007 Enrollment

Application

Please Type or Print Legibly
Name_________________________        ___________________            ______

                                Last                                  First                                      MI

SS#____________________________      Student ID#                                     

Date of Birth_____________________            Sex   ____M     ____F
Home Address____________________  _______________  ________   _________

                      Street                                     City                 State            Zip

County _____________    Home Phone#____________     Cell Phone#___________

Email Address_______________________________________

Name of High School Attended__________________________

High School Graduation Date or Date of G.E.D. Completion _________________

Total S.A.T. Score_________                                G.E.D. Score ________________

Verbal S.A.T. Score________                                Math S.A.T. Score_________

ACT Score_______________

Race or National Origin:

  ____Black, Not of Hispanic descent  ____White, Not of Hispanic descent
  ____Hispanic                                  ____Asian or Pacific Islander

  ___American Indian                         ____Other                                        (Please Specify)

       or Alaskan Native                   

   Edinboro University of Pennsylvania is committed to affirmative action to

   ensure an equal opportunity for all persons, regardless of race, color,
   national origin, ancestry, religion, or sex.

   The following is necessary to determine eligibility for the program. Please answer as best you can.
   I am

   ____*Financially Dependent (Rely on parent(s), or guardian for financial support-food, housing, etc.)          
   ____  Financially Independent (totally self-supporting or head of household).

           *If financially dependent, please have a parent or guardian assist in completion of this portion of the form.

            Number of persons in immediate family in your household:  ____

1.       Total Yearly Earned Income from Latest Tax Return  _______________

(Designated as Adjusted Gross Income)

2.    Non-Taxable Income  ___________________  

       (Public Assistance, Social Security, Unemployment Compensation, Veteran’s Benefits)

3.       List children or others in your household other than the applicant who attend a College or University (or other

(Post High School Educational Institution) and the Institution

CHILD’S NAME                                                                       EDUCATIONAL INSTITUTION

1. _____________________                                          _____________________________ 

2.  ____________________                                           _____________________________

3. ____________________                                           ______________________________

4. ____________________                                          ______________________________

How many children, including the applicant, depend on the family for support?  ____

    Do you take all of your courses in a program of campus? If yes, please check where:

    ___ Porreco               _____ East Erie                _____  Meadville

AFFIDAVIT

I certify that the above information is true and correct

 _______________________________                            ___________

Signature of Student                                                            Date

 ______________________________                               ____________

Parent/Guardian (if student is under 18 years of age)             Date

Office Use only:

Date of Application Received: _________

Accepted:  ______Yes   _____ No

Date of Application Approved/Rejected: ______