Application for Services

Completion of the Application for Services form allows you access to register for the virtual ACCUPLACER assessment and apply for additional services through the Educational Opportunity Center (EOC), Office of Nontraditional and Evening Services (ONES), and TRIO programs.

First Name

Middle Name

Last Name

Date of Birth

Mercer ID

Contact Information

Mailing Address

Country

Street

City

Region

Postal Code

Home Phone:

Cell Phone:

Do you consent to receiving text messages from the this office about important updates?

Yes

Email Address:

Please provide the email address to which you would like your Accuplacer enrollment voucher to be sent. We prefer that you provide your Mercer email address.

Gender

Female

Male

U.S. Citizen

Are you a U.S. Citizen?

Yes

If no, are you a permanent resident?

Yes

If yes, list alien number

Ethnicity and Race

Are you Hispanic/Latino?

Yes

If no, select one or more races that best describes you:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Background Information

What is your highest level of education completed?

Student Classification

What is your anticipated enrollment status?

Full-time

Part-time

Degree you are seeking at Mercer University

Does your mother have a bachelor's (4-year) degree?

Yes

Does your father have a bachelor's (4-year) degree?

Yes

With whom do you live?
(Check all that apply)

Mother

Father

Spouse

Other

Do you have a documented learning or physical disability?

Yes

Will you apply for financial aid?

Yes

What types of financial aid have you been awarded or will you receive for the academic year?
(Check all that apply)

Scholarships

Pell Grant

Other Grants

Loans

Work-Study

None

Do not know

Do you participate in a TRIO Educational Talent Search Program?

Yes

Family Information

What is your marital status?

What is your family size?

Are you a dislocated worker?

Yes

Are you, your spouse, or a parent on active duty in the military/reserves?

Yes

Are you a veteran of the U.S. Armed Forces?

Yes

What is your family's annual taxable income?

Academic Profile and Assessment

Check all that apply

I have been out of school 5 or more years

I have low college grades or GPA

I have failed a course while in college

I am undecided about my future

I have limited English Proficiency

I find writing challenging

I find math challenging

I find reading textbooks challenging

I am undecided about my major

Other

What else would you like to share about your academic profile?

Services Needed

Which of the following services are you most interested in?
Check as many as needed

Academic Assistance/Academic Skills Coaching

Admissions Info/Assistance

Career Info/Assistance

Counseling and Disability Referral Services

Financial Aid Info/Assistance; TRIO Grant Aid

Financial Literacy/Budget Planning

Graduate School Preparation

Grant Aid

Improving Computer Skills

Improving Presentation Skills

Major and Career Exploration

Minimizing Loan Debt Assistance

Parenting/Daycare Assistance

Scholarship Assistance

Student Loan Entrance Counseling/Promissory Note

Tutoring

Wellness

Other

What other services are you interested in?

Release of Records and Information Agreement

To the best of my knowledge, my information is complete and correct. I understand that I will receive services to help me plan and complete my educational and career goals. In addition, I authorize the Educational Opportunity Center/Student Support Services Office to release and obtain academic, enrollment, and financial aid records required to assist me in completing my educational and career plans. I also permit using my name and/or photograph for editorial, promotional, recruitment, and educational purposes.

In place of your signature, please type your full legal name:

Date:

Application for Services

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