PASS Program Application

Student Information

Name*

First Middle Last

Lancer ID*

Date of birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number*

Phone Number 2

Email*

Enter Email Confirm Email

Gender*

Marital Status*

Do you have children?*

Yes
No

Are you a former foster youth or ward of the court?*

Yes
No

I identify my racial/ethnic background as:*

Asian
Black/African
Caucasian/White
Hispanic/Latina/o/x
Native American
Pacific Islander
Mixed Race
Other

Other racial/ethnic background:*

How did you hear about the PASS?*

How can PASS best support your educational goals?*

Check all that apply

Program Eligibility

Federal regulations state that in order to be eligible for PASS an applicant must: (1) Be a U.S. citizen or permanent resident, (2) be low-income and/or a first-generation college student and/or a student with a verified disability, and (3) have an academic need. The following questions will help the program determine your eligibility.

Citizenship Status*

Choose one

United States Citizen
Permanent Resident

Permanent Resident Card #*

Attach a copy of your Permanent Resident Card*

First Generation College Student Status

Did any of your parents (natural or adoptive) receive a bachelor’s degree from a college or university?

Mother*

Yes
No
N/A or Don’t know

Father*

Yes
No
N/A or Don’t know

Other

Yes
No
N/A or Don’t know

Low-income Verification

I am applying as:*

Independent (24 years old or above)
Dependent (23 years old or below)

Independent Section

Independent Students: You must provide your most recent income tax information. Tax information is found on the following forms: 1040 line 43, 1040-A line 27 or 1040-EZ line 6.

What is the total number of persons (including you) in your family?*

Did you file a federal income tax return last calendar year?*

Yes
No

In which state did you file your return?*

What was your TAXABLE income?*

(Not your total income)

What was your TOTAL income?*

Dependent Section

Dependent Students: Parent/guardian must provide their most recent income tax information. Tax information is found on the following forms: 1040 line 43, 1040-A line 27 or 1040-EZ line 6.

What is the total number of persons (including you) in your Parent/Guardian family?*

Did your parent/guardian file a federal income tax return last calendar year?*

Yes
No

In which state did your parent/guardian file their return?*

What was their TAXABLE income?*

(Not their total income)

What was their TOTAL income?*

Sources of Income

Check source(s) of income:*

Full-time employment
Part-time employment
Welfare AFDC
SSI
Child Support
Veteran benefits
Unemployment
Other Sources

Other source(s) of income*

Do you have a disability?*

Yes
No

Are you registered with the PCC Disabled Student Program and Services (DSPS)?*

Yes
No

Please attach DSPS documentation*

Academic Need*

Check all that apply

I have a high school or college GPA below a 2.50
I have multiple withdrawals (“W”) in degree or transfer courses
I have difficulties passing transfer level courses
English is not my native language
I have been out of school for more than 5 years
Other

Other Academic Need(s)*

Educational History And Goals

Academic major*

What is your educational goal at PCC*

Choose one

Transfer with an Associate Degree
Obtain an Associate Degree only
Transfer without an Associate Degree

Where would you like to transfer?*

List your top three choices in order of preference. Use the "+" button to add additional choices

College(s) previously attended

Are you a High School graduate?*

Yes
No

High School Name*

Graduation Date*

High school cumulative GPA

Did you finish a GED or high school completion program?*

Yes
No

Date you completed the GED*

Have you participated in, or are you currently in, any of the following programs?

Check all that apply

Application Questions

Answer the following short answer questions. Your responses to these questions are required and will help the program determine your motivation to participate in PASS.

1. What are your educational goals and career goals?*

2. What are potential circumstances that might affect you reaching your academic goals at PCC?*

3. Is there anything else that should be taken into consideration in evaluating this application?*

Certification

Certification*

By checking this box I certifiy:

The information submitted on this application is true and correct, and that all documentation is accurate. I authorize the release of my information and academic records to the Program for Academic Support Services (PASS) to determine my eligibility for the program and for statistical reporting purposes. I understand that the goal of PASS is to increase the retention, graduation, and transfer rates of program participants; therefore, if admitted into the program, I will actively participate in PASS until I complete my educational goal at PCC.

Email

This field is for validation purposes and should be left unchanged.