Submit Your Application

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

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.

First Name *

Middle Name

Last 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? *

Who did you reside with in high school or when you are home from college for breaks? *

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 or other documentation for proof of disability (504 Plan or IEP)

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

Were you born before January 1, 2000 *

Are you currently Married?

Are you a veteran of the US Armed Forces? *

Are you currently serving on active duty in the U.S. armed forces for purposes other than training? (If you are a National Guard or Reserves enlistee, are you on active duty for other than state or training purposes?)

Do you have dependents—other than your children or spouse—who live with you and who receive more than half of their support from you, now and through June 30, 2024?

Do you now have—or will you have—children who will receive more than half of their support from you between July 1, 2023, and June 30, 2024

At any time since you turned age 13, were both your parents deceased, were you in foster care, or were you a dependent or ward of the court?

Are you an emancipated minor or that someone other than your parent or stepparent has legal guardianship of you?

If you have answered YES to any of the above questions you are INDEPENDENT

What is your Taxable Income (line 15 of form 1040) Must Enter a # *

What is your Parent(s) Taxable Income (line 15 of form 1040) Must Enter a #

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) *

Please Upload one of the following for parent proof of income: Signed IRS 1040 or Signed statement of taxable income (see example below) can be a picture of the document. *

ACADEMIC NEED: Check ALL That Apply (Must Check at least One):

Low Admission Test Scores (ACT, SAT, ACCUPLACER

Low High School Grades (Any D or F)

Low College Grades (C or Lower)

Failing Grades (D or F in any class)

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)

I am interested in academic support/tutoring

I need to improve my study habits and skills.

I need access to technology resources such as a computer lab and printing.

I need assistance with the financial aid process and FAFSA.

I need assistance with choosing a career path, resumes, cover letters, or interview skills

Academic I would like to receive academic advising for my major.

I am distracted by personal matters to the point that I am having trouble studying/keeping up with assignments.

I need personal support and encouragement.

I would like to attend cultural activities e.g., museums, theater, etc.

I would like to participate in activities that benefit others e.g., Community Service

I would like to develop my leadership skills.

I struggle with time management and would like help utilizing my time more efficiently.

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 *

Signature Type: Simple Start Over

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Signature: (Type in your full name)

I agree to the terms included.

Parent Signature (must be signed by parent if dependent student)