Submit Your Application



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. You may want to review the included items, take some time to make notes and gather the required documents, and then return to submit your application. If you have any questions, please call our office at (334)-347-2623 ext. 3626 in Enterprise or ext 3624 in Ozark.

General Information:
Last Name: *
First Name: *
Middle Name: *
School ID (A#) *
Date of Birth (DD/MM/YYYY): *
Gender * Male Female Nonbinary or another gender No response/Unknown
Ethnicity * No response American Indian or Alaska Native Asian Black or African-American Hispanic or Latino White Native Hawaiian or other Pacific Islander More than one race reported
Are you a US citizen? * Yes No
Are you a permanent resident of the United States? * Yes No
Address: *
Address 2:
City: *
State: *
Zip Code: *
Primary Phone
Cell Phone
Email Address: *
Describe your primary reason for applying: *
Do you have either of the following: * High School Diploma GED Neither
Do you have either of the following? 2 Year Degree 4 Year Degree Both Neither
Are you a returning adult student (beginning college at age 23 or later)? Yes No
If you answered yes to the previous question, how many years has it been since you last attended school?

Academic Info:
Major *
Degree Plan * AS AA AAS
What are you plans after attending ESCC? Transfer to another school Enter the workforce
College Grade Level (Start) * No response/Unknown 1st yr., never attended 1st yr., attended before 2nd yr./sophomore 3rd yr./junior 4th yr./senior 5th yr./other undergraduate Dual degree program Graduate/Professional Student Not applicable (New summer participant- summer session only) Not applicable (prior-year participant no longer enrolled and bachelor’s degree recipients) Not applicable (prior-year participant no longer enrolled at grantee institution)
How many classes are you taking this semester? * 1-2 3-4 5+
Current GPA: *
How's your academic standing? * Good On Probation I don't know
Have you previously participated in any of the following? Select all that apply. * Upward Bound Talent Search Student Support Services None of the above
Are you registered with our ADA office for classroom accommodations? * Yes No

Federal Eligibility Information:
Mother's (or female guardian) Educational Level: * Bachelor's Degree or Higher Associate's Degree Certificate High School Diploma/GED None of the above Unsure
Father's (or male legal guardian) Educational Level * Bachelor's Degree or Higher Associate's Degree Certificate High School Dipoma/GED None of the above Unsure
Most Recent IRS 1040 (If you do not have access to this document, answer all questions in "Income Verification" section.)
Do you currently receive financial aid (Pell, scholarship, student loans, etc.)? Please specify type. *

Income Verification: You do NOT have to complete this section if you were able to upload your 1040 in the previous section.
Which of the following statements best describes your status? I am a dependent student (age 23 and under, single, have no children, no military affiliation). I am an independent student (age 24 and up, married/separated, have children, active military, veteran).
How many people in your household at home? 1 2 3 4 5 6 7 8
Family Income Range: $0 - $19,140 $19,141 - $25,860 $25,861 - $32,580 $32,581 - $39,300 $39,300 - $46,020 $46,021 - $52,740 $52,741 - $59,460 $59,461 - $66,180 Over $66,181

Sign and Submit:
Applicant Signature * Please select a signature verification type.
Terms of Submission: By submitting this application, you acknowledge that all of the above information is correct and accurate to the best of your understanding.