Veterans Upward Bound Application for Services | University Studies

Personal Information

First Name

Middle Initial

Last Name

Email Address

Preferred Phone Number

Date of Birth

Street Address

City

State

Zip Code

Participant Demographics

Employment

Unemployed

Part Time

Full Time

Retired

Disability

Yes

Gender (Check all that apply)

Male

Female

Transgender

Non-binary/non-conforming

Prefer not to respond

Are you Hispanic/Latino?

Yes

Race (Check all that apply)

American Indian/Alaskan Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Education

High School

Have you completed High School?

High School Graduate

G.E.D. Graduate

Not Completed

Date of last enrollment/graduation

College

What is your college experience?

Never Enrolled

Not Completed

Currently Enrolled

Graduated

Degree Type Completed

A.A./A.S.

B.A./B.S.

Certication

N/A

Other

Date of last enrollment

Do you have a defaulted student loan?

Yes

Unsure

Military Service

Service (Check all that apply)

I served on active duty as a member of the Armed Forces of the United States for a period of more than 180 days.

I served on active duty as a member of the Armed Forces of the United States and was discharged or released because of a service connected disability.

I was a member of a reserve component of the Armed Forces of the United States and was called to active duty for a period of more than 30 days.

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

Branch

Air Force

Marine Corps

Coast Guard

Army

Navy

Reserve/NG

Discharge

Honorable

General

Bad Conduct

Dishonorable

Other than Honorable

Other…

Date of most recent discharge

Are you eligible for G.I. Bill education benefits?

Yes

Unsure

First Generation Status

Did either parent or guardian with whom you resided have a bachelor’s degree prior to you turning 18? Please provide this information only for those parents/guardians living in your former household.

Mother/Female Guardian

Yes

Father/Male Guardian

Yes

Income

Did you file a tax return last year?

Yes

I filed an income tax return last year. The number of individuals currently living in my household and/or claimed as dependents (including myself) is:

Taxable income for last year was

Please note that taxable income is different from gross or net income.

I was not required to file a tax return last year. The number of individuals currently living in my household and/or claimed as dependents (including myself) is

My total non-taxable income for last year (from all sources) was:

Citizenship

Are you a Citizen, National, or Permanent Resident of the United States?

Yes

If “No”, do any of these situations apply?

I am in the United States for other than a temporary purpose. Please provide evidence from the Immigration and Naturalization Service of your intent to become a permanent resident.

I am a permanent resident of Guam, the Northern Mariana Islands, or the Trust Territory of the Pacific Islands.

I am a resident of the Freely Associated States – the Federated States of Micronesia, The Republic of the Marshall Islands, or the Republic of Palau.

How Did You Hear About Veterans Upward Bound?

Referral from community agency

Referral from veterans’ agency (VA, Vet Center)

Our website

Referral from a school or educational institution

Word of mouth/walk-in

Referral from another TRIO project

Referral from non-TRIO program

Other…

What type of educational services are you looking for?

Applicant signature

I would like to participate in the Veterans Upward Bound program and receive the free services provided.

I hereby certify that the information provided in this application is accurate and complete to the best of my knowledge.