Student Support Services General Application

Educational Progress

High School Attended

High School Graduation Date

Semester/year admitted to NIU:

Estimated graduation date from NIU:

Would you like to have a peer mentor?

Are you a parent?

Did you attend any other colleges or universities prior to coming to NIU?

College 1

College Name

Dates of Attendance

Started:

Finished:

Degree Earned

Total number of credits earned:

Total number of credits transferred:

Would you like to add an additional school?

College 2

College Name

Dates of Attendance

Started:

Finished:

Degree Earned

Total number of credits earned:

Total number of credits transferred:

Would you like to add an additional school?

College 3

College Name

Dates of Attendance

Started:

Finished:

Degree Earned

Total number of credits earned:

Total number of credits transferred:

General Information

How did you learn about the Student Support Services program?

Are you employed?

Approximately how many hours per week do you work?

Are you receiving financial aid at this time?

If you are receiving a Pell Grant, what is the amount of your annual award?

Do you plan to apply for financial aid in the future?

Do you intend to continue your education after graduation?

In what area of study?

In what field would you like to work after graduation?

What do you see yourself doing five years from now?

In your own words, please explain briefly why you want to participate in the Student Support Services Program

Authorization to Release Information

I hereby grant permission for the Northern Illinois University Student Support Services (SSS) program staff to access my academic and financial aid records for the purposes outlined below.

Student Support Services requires access to my academic records and financial aid information to verify my eligibility for the program and provide personalized advising, academic support, and to track my progress toward the successful completion of my degree. This access is necessary for the program to fulfill its obligations to its funding agency, the U.S. Department of Education.

The following information may be accessed by SSS staff:

Unofficial transcripts and grade reports from my college/university.
Financial aid award letters and related financial information each semester that I am enrolled in a post-secondary institution.

I understand that Student Support Services will use this information for academic advising, monitoring my academic progress, and assisting me in achieving my educational goals. My information will be stored securely and only shared with staff members directly involved in providing services to me or program oversight in compliance with the U.S. Department of Education regulations.

This consent will remain in effect until I provide written notice of revocation. I understand that any revocation will not apply to information that has already been disclosed prior to the written revocation.

Please type your name and Z-ID below to approve release of your academic and financial aid information.

Full Name

NIU Z-ID

Certification

I certify to the best of my knowledge that the information I have provided on this application is correct. I authorize Student Support Services to verify the information I have given to qualify for the program and to gather other data required to extend program services.

I agree

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