Application

MM/DD/YYYY

Are you a U.S. Citizen? If you are not a U.S. Citizen, answer the next question

*From 2016 Income Tax, Form 1040 Line 43, Form 1040A Line 27, Form 1040EZ Line 6

I declare that the information on this form is true to the best of my knowledge. The UALR Educational Opportunity Center Program is authorized to access information deemed necessary to assist me in achieving my educational goals or in meeting the reporting requirements of the U.S. Department of Education, to record pertinent facts regarding my eligibility in the Program, services rendered, and placement. A copy of this statement shall serve as such authorization.