Social Security Number: (Last 4 digits)

Last Name:First Name: MI:

Address:

City:   State:   Zip-Code:

Home Phone: Work Phone:

Email Address:

Date of Birth: mm/dd/yyyy

 Ethnic Background: Select One Amer. Indian / Alaskan Native Asian Black / African American Latino / Hispanic Caucasian (White) Hawaiian / Pacific Islander More than One Race

 Employment Status: Select One Full Time Part Time Unemployed

 Are you a U.S. Citizen?
     Yes
     No - Eligible non-citizen number: A

 Limited English Proficiency                 Are you a Veteran?   
     Yes     No                            Yes       No 

Has either of your parents received a four-year Bachelor's degree  in     college?
     Yes           No

 Select the number of people in your family unit: Select One 1 2 3 4 5 6 7 8 9 10 or greater

 Do you have a high school diploma?
     Yes            No

 Select Highest Grade Completed: Select One 6 7 8 9 10 11 12 GED

 Select Vocational Grade Completed: Select One Not Applicable 1 2 3
 Select College Grade Completed: Select One Not Applicable 1 2 3 4

Have you every attended college?
     Yes - Where?
      From: (mm/dd/yyyy) to (mm/dd/yyyy)

     No

 Have you earned a Bachelors Degree (4 yr. College degree)?
     Yes              No

 How did you learn about the EOC center?
     Friend / Relative
     Newspaper
     Radio/TV
     High School Counselor
     Workshop/Presentation
     Agency
     Other

I understand that the above information will be used to evaluate this project for reporting to the US Dept of Education.  By checking this box, I testify that all statements made are true to the best of my knowledge.