Thank you for your interest in Jackson State University’s TRIO Student Support Services Premier Program.

Please note that this application cannot be saved and restarted, so ensure you have the required information ready before you begin.

Information You Will Need:

  • Family size (number of people living in your household)

  • Taxable income for your household

  • One income verification document, if you indicate that you meet the federal low-income guideline

Accepted Income Verification Documents:

  • Signed parent/legal guardian income statement

  • Verification from a government agency (SNAP, TANF, etc.)

  • Signed FAFSA or Student Aid Report (SAR)

  • Signed U.S. or Puerto Rico tax return

If you are a dependent student, your parent or legal guardian will need to provide the income information used for verification.  Independent students, those who provide their own financial information rather than a parent’s, should submit their own income documentation.

If you have any questions, please contact our office at (601) 979-3765 or (601) 979-1049.

DEMOGRAPHIC INFORMATION
Last Name *
First Name *
Middle Name *
School ID *
Cell Phone Number *
Email Address *
Permanent Address *
Permanent City *
Permanent State *
Permanent Zip Code *
Gender *
Date of Birth *
SA Ethnicity *
Do you identify as any of the following? *

PROGRAM ELIGIBILITY INFORMATION
Which of the following best describe your citizenship status? *
Are you currently enrolled at Jackson State University or accepted for the next upcoming semester? *
Do you feel you would benefit from additional academic support to help you be successful in college? *
If "yes" or "maybe", which area(s) of support would be most helpful? (Check all that apply) *
Are you a first-generation college student (neither parent/guardian has a bachelor's degree)? *
Do you have a documented disability? *
All documented disabilities should be registered with the JSU Accessible Education and Resource Center (Student Center, 2nd Floor, Room 2110 | 601.979.3704).

INCOME-BASED ELIGIBILITY INFORMATION
How many people are in your house hold? *
Does your family’s taxable income fall at or below the amount listed for your family size? *
For the most recent tax year, what is your household’s taxable income (parent/guardian if dependent, your own if independent)? *
Please upload your income verification document. Submit any of the accepted documents listed in the introduction. Dependent students must provide parent or guardian documentation. *
Please select the type of income verification document you are uploading: *

ACADEMIC INFORMATION
Major: *
College Classification: *
Are you a transfer student? *
Have your earned a degree from another college insitution/university? *
If you selected "yes", list the degree below and the institution. *
Current GPA? *
Have you been a program participant in any of the following TRIO Programs? (Select all that apply?) *

Certification Statement

I certify that all information provided in this application, including demographic information, program eligibility responses, income-based eligibility documentation, and academic information is true, complete, and accurate to the best of my knowledge. I understand that providing false or misleading information may affect my eligibility for the TRIO Student Support Services Program. I acknowledge that all documentation submitted accurately reflects my household’s circumstances.

 
Applicant's Signature: *
Signature Type: SMS    Start Over
After validation, the cell phone number will become part of the electronic signature.
Cell Phone Number:

Income Information Provider Signature *
Signature Type: SMS    Start Over
After validation, the cell phone number will become part of the electronic signature.
Cell Phone Number:

Date *
PROGRAM PARTICIPANT REQUIREMENTS
Please initial each item below to acknowledge your understanding and agreement with these requirements if accepted into the TRIO SSS Program.
Participant agrees to meet with SSS staff at least three (3) times per semester for academic advisement.
Participant agrees to participate in at least one (1) cultural/academic enrichment event per year. (if applicable)
Participant agrees to attend the mandatory orientation and three (3) Student Success Workshops.
Participant agrees to attend at least one four-year college/university campus visit (if applicable for graduate studies).
Participation agrees to participate in /tutoring and/or instruction. (if applicable)
PARTICIPATION & PHOTO RELEASE AGREEMENT
Initial in the space provided to indicate your understanding and agreement.
I understand my participation in Jackson State University TRIO SSS Program activities is voluntary and I agree to follow program guidelines.
I give permission for Jackson State University TRIO SSS Programs to photograph or record me during program activities.
I allow Jackson State University TRIO SSS Programs to use my photos, videos, or statements for program materials, social media, and reporting.
I understand I will not receive compensation for the use of my image.
I may withdraw photo permission in writing, but this does not apply to materials already created.
I release TRIO Student Support Services Programs and Jackson State University from liability related to participation or image use.