Brown Hall Suite 345, 105 West O Street, Russellville, AR 72801

trio.sss@atu.edu    479-880-4172

 

 

Thank you for your interest in our Student Support Services program. Please complete this application as thoroughly as possible. You cannot save and restart this application. 

 

Last Name *
First Name *
Middle Name
Student T-Number *
Date of Birth *
Address *
City *
State *
Zip *
Email Address *
Cell Phone Number *
Gender *


RACE & ETHNICITY: Please choose ALL that apply

Hispanic *
American Indian or Alaskan Native *
Asian *
Black or African American *
Hawaiian or other Native to Pacific Island *
White *

ELIGIBILITY
Citizenship *
Did your Mother graduate with a 4 year bachelor's degree? *
Did your Father graduate with a 4 year bachelor's degree? *
What is your Major? (If you're not an education major, please fill out the Student Support Services Application at www.atu.edu/sss) *
Education *
Year Graduated High School *
Do you have a documented physical or learning disability? *
If Yes, have you registered with Tech's Disability Services?
Upload a copy of your disability accommodations letter from your online portal

FINANCIAL ELIGIBILITY
Have you completed the FAFSA?
Check box if you are receiving Pell Grant
Check box if you are receiving Student Loans
Check box if you are receiving Scholarships
Check box if you are receiving work-study
What is your Parents Taxable Income (line 15 of form 1040) *
What is your Taxable Income (line 15 of form 1040) *
When you are not in school, who do you reside with? *
How many people are in your family/ live in your household? (Include those away in school and yourself) *
Do you have any children? *
2020 Taxes IRS 1040

ACADEMIC NEED: Check ALL That Apply (Must Check at least One):
Low Admission Test Scores (ACT, SAT, ACCUPLACER
Low High School Grades
Low College Grades
Failing Grades
Out of school for more than 5 years
Limited English Proficiency
Lack of educational/career goals
Lack of Academic Preparedness
Need for academic support to raise grades in required courses/major

Check the services which are of greatest need: (Must check at least One)
Tutoring
Study Skills
Computer Lab/Technology
Financial Aid Information
Career Advising
Academic Advising
Mentoring/Counseling
Leadership Skills
Cultural Enrichment
How did you learn about Student Support Services? *


SIGN AND SUBMIT:

Student Informed Consent Agreement

I certify that the information I have provided is true and correct to the best of my knowledge. I give my consent for Arkansas Tech University Student Support Services Program to release and receive academic and/or financial aid information in order to provide appropriate services.

Applicant Signature *
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Signature: (Type in your full name)
I agree to the terms included.
Parent Signature
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