SUBMIT APPLICATION. Submit your original application along with all academic and personal items noted above by mail or in person.

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1 TRIO UPWARD BOUND APPLICATION CHECKLIST All of the following items must be submitted with your application before you are considered for enrollment. This information is required by the U.S. Department of Education to verify and document student eligibility for the TRIO Upward Bound Program. Please note that all information will be kept in the strictest of confidence. Application To Be Completed by You and Your Parents Complete each section of application legibly Review, sign, and date as required Gather all academic and personal items noted below* Submit application package by mail or hand deliver *Academic Related Items - Ask Your High School Counselor or Registrar Middle School Transcript High School Transcript (if applicable) PARCC Partnership for Assessment of Readiness for College and Careers (7 th and 8 th grade results) Copy of most current Report Card or Progress Report *Personal Related Items Ask Your Parents Signed Copy of Parent/s 1040/1040A U.S. Income Tax Return Signed Copy of Student s Social Security Card Copy of Student s Birth Certificate Copy of Permanent Resident Card or INS Form (non US Citizens only) Copy of Legal Guardianship Document (only students not living with parents) SUBMIT APPLICATION Submit your original application along with all academic and personal items noted above by mail or in person. Mailing Address: Physical Address: Program 30001, MSC 5278 Las Cruces, NM Hardman and Jacobs Undergraduate Learning Center Student Success Center - Room McFie Circle Las Cruces, New Mexico More information: Tel: (575) Fax: (575) trioub@nmsu.edu Web: trioub.nmsu.edu The NMSU Program is funded under TRIO Grants from the U.S. Department of Education

2 PERSONAL Legal Name Nombre Legal Last Apellido First Primer Nombre Middle Segundo Nombre SSN/Gender Seguro Social/Género Date of Birth Fecha de Nacimiento Place of Birth Lugar de Nacimiento Social Security Number Número de Seguro Social MM/DD/YYYY City, State, Country Ciudad, Estado, País Gender Género Female Femenino Age Edad Male Masculino Citizenship Ciudadanía Hispanic/Latino Hispano/Latino Race (check one) Raza (escoger uno) Primary Language Spoken at Home Idioma Primario Hablado en Casa United States Citizen Ciudadano de los Estados Unidos Permanent Resident Alien Registration Number: Residente Permanente Extranjero Número de Registración Yes No American Indian/Alaskan Native Indio Americano/Nativo de Alaska Black/African American Afroamericano White Blanco Asian Asiático Native Hawaiian/Other Pacific Islander Nativo de Hawái / Otras islas del Pacífico English Inglés Spanish Español Other Otra: ADDRESS Mailing Street or Calle o Caja Postal City Ciudad State Estado Zip Code Código Postal Physical Provide only if different from mailing address TELEPHONE/ Student Estudiante Mother Madre Father Padre Legal Guardian Guardián Legal Street or Calle o Caja Postal City Ciudad State Estado Zip Code Código Postal Cell Number Número de Celular Alternate Number Número Alternativo Correo Electrónico The NMSU Program is funded under TRIO Grants from the U.S. Department of Education 1

3 EDUCATION High School Inscripto/a en Grade Level Nivel de grado High School Information Información de escuela secundaria Name of High School Counselor Nombre del Consejero de la Escuela Secundaria Middle School Attended Escuela Intermedia Atendida Gadsden Las Cruces Mayfield Oñate Santa Teresa 9 th 10 th 11 th 12 th Graduation Year Año de Graduar HS CUM GPA Promedio escolar School ID Number Número Escolar Last Apellido First Primer Nombre Middle Segundo Nombre EXTRACURRICULAR ACTIVITIES List all extracurricular None activities you are participating in. Educational: Lista todas las actividades extracurriculares en cual Sports: participas. Personal: Other: EMPLOYMENT Are you employed? Estás empleado? Place of Employment Lugar de Empleo: Work Schedule Horario de Trabajo: The NMSU Program is funded under TRIO Grants from the U.S. Department of Education 2

4 PARENT/LEGAL GUARDIAN Who do you live with? Mother and Father Madre y Padre Con quién vives? Mother and Step Parent Madre & Padrastro/Madrastra Father and Step Parent Padre & Padrastro/Madrastra Date of Marriage Fecha de matrimonio: Date of Marriage Fecha de matrimonio: Mother Only Solo Madre Father Only Solo Padre Legal Guardian Tutor Legal Other Otro If living with legal guardian, provide requested information. Si vive con el tutor legal, proporcione la información solicitada. PARENT S EDUCATION MOTHER Madre Highest Grade Level Completed Nivel más alto completado Bachelor degree? Ha recibido licenciatura? Name: Relation: Are your parent s deceased? Fallecieron sus padres? Yes No Legal Name Nombre Legal Employer Empleado Work Telephone Número de trabajo Example: 11 th grade, GED, some college Ejemplo: grado 11, GED, algún colegio Master/doctoral degree? Ha recibido maestría o doctorado? Mother s Signature Firma de Madre FATHER Padre Highest Grade Level Completed Nivel más alto completado Bachelor degree? Ha recibido licenciatura? Master/doctoral degree? Ha recibido maestría o doctorado? Father s Signature Firma de Madre Legal Name Nombre Legal Employer Empleado Work Telephone Número de trabajo Example: 11 th grade, GED, some college Ejemplo: grado 11, GED, algún colegio STEP PARENT Padrastro/Madrasta Highest Grade Level Completed Nivel más alto completado Bachelor degree? Ha recibido licenciatura? Legal Name Nombre Legal Employer Empleado Work Telephone Número de trabajo Example: 11 th grade, GED, some college Ejemplo: grado 11, GED, algún colegio Master/doctoral degree? Ha recibido maestría o doctorado? Step Parent s Signature Firma de Padrastro/Madrastra The NMSU Program is funded under TRIO Grants from the U.S. Department of Education 3

5 FAMILY List every person living in your household. Attach additional page if necessary. Entre todas las personas que viven en su hogar. Adjunte una página adicional si es necesario. Full Legal Name Nombre Completo Age Edad Relation To You Relación A Ti 1. Self/Student The NMSU Program is funded under TRIO Grants from the U.S. Department of Education 4

6 ABOUT YOU Tell us about yourself. Cuéntanos acerca de ti. What are your three goals after graduating from high school? Cuáles son sus tres metas después de graduarse de la escuela secundaria? What is your main career interest? Cuál es su interés profesional? Why? Por qué? Are you interested in a STEM (Science, Technology, Engineering, and Mathematics) related career? Está interesado en una carrera relacionada con STEM (Ciencia, Tecnología, Ingeniería y Matemáticas)? Why do you want to be in the Upward Bound Program? Por qué quieres estar en el Programa Upward Bound?, in Science Technology Engineering Mathematics Applicant s Signature Firma de candidato The NMSU Program is funded under TRIO Grants from the U.S. Department of Education 5

California State University, Los Angeles TRIO Upward Bound & Upward Bound Math/Science

California State University, Los Angeles TRIO Upward Bound & Upward Bound Math/Science Application must be completed in black or blue ink only. STUDENT INFORMATION Name: Social Security # - - First Middle Last Address: Apt.# Phone: ( ) City: State: Zip Code: Date of Birth: Place of Birth: