Student Support Services Online Application

Buffalo State College

Fields marked with a (*) are required. You must fill them out. This form may take approximately 10-20 minutes to complete.

Be sure to consult the eligibility criteria before you submit the form. The criteria will open in a new window by clicking here.

Your e-mail (must be valid):*

Last Name:
 First Name:
 Middle Initial:

Please come to the office or call us to provide your Social Security Number.

Your Addresses

Local Address:

City:

State:

ZIP:

Permanent Address:

City:

State:

ZIP:

Date Of Birth:*

Gender

Male:

Female:

Phone Contact Information

Local Phone:*

Permanent Phone:*

Alternate Phone:

Your Ethnicity and Citizenship Status:

African-American:
Asian-American:
Caucasian:
Hispanic/Latino:
Native American:
Other Ethnicity:
  
Citizenship:

U.S. Citizen:

U.S. Permanent Resident:
U.S. Territorial Resident:

Referred by:

Are you an Educational Opportunity Program (EOP) student?

Has your father received a Bachelor's Degree?

Has your mother received a Bachelor's Degree?

If you have a disability, check the small box and specify the disability in the larger box.

Have you received any financial aid awards at Buffalo State College? Check this box and any of the funding types you have received:

Pell Grant:

TAP:

Student Loans:

Other Funding Sources

VESID:

SSI:

 CBVH:

Social Services:

 SEOG:

Self/Family:

Do you meet one or more of the low-income level criteria?

Are you a full-time, matriculated undergraduate student?

I request academic and counseling support through the Student Support Services Program (SSSP) to achieve my educational and career goals. All of the information on this form is correct and complete to the best of my knowledge. I authorize the SSSP to secure any information necessary to determine my eligibility and ensure my success.
Applicant Signature (Print your name):*
Date:*

Credit Hours To Date:

Current GPA:

Declared Major:

Exected Graduation Date:

Date you entered BSC:

College Prevously Attended:

Is English your first language?

Other program affiliation?

Special Services:

Academic Talent Search:

Upward Bound:

How did you choose your major? If you haven't yet, what fields interest you?

What career path would you like to pursue after graduation?

What personal factors—such as your own self-image, your family situation, etc. might impact your academic progress?

What help would you like from Student Support Services?

Please check all that apply.

Academic Counseling:

Personal Counseling:

Career/Graduate School Counseling:

Financial Aid Counseling:

Reading Skills:

Study Skills:

Tutoring:

Peer Mentoring:

Social Events:

Writing Skills:

Academic Workshops:

Computer Skills Workshops:

Study Groups:

Cultural Experiences:

Math Skills:

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