The Colorado State University - Pueblo
2200 Bonforte Boulevard, Colorado 81001 		Telephone - (719) 549-2875
Fax - (719) 549-2914
     
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Colorado State University - Pueblo
2200 Bonforte Boulevard
Pueblo, Colorado 81001
(719) 549-2875
(719) 549-2914 (FAX)
Pikes Peak Community College
5675 S. Academy Blvd, Room A-116
Colorado Springs, Colorado 80906
(719) 502-4545
(719) 579 - 3079 (FAX)
Pueblo Community College
Administration Building
900 W. Orman
Pueblo, Colorado 81004
(719) 549 - 3077
(719) 549 - 3097 (FAX)
Name Title
Street Address Address (cont.)
City State/Province
Last 4 ID Number Date of Birth
Sex Male Female Marital Status
Zip/Postal Code Country
Number of Dependents Work Phone
Home Phone Mobile Phone
Alien Resident Visa Number
Ethnic background

 Military Service
Character of discharge Education background
First generation status Income status
Eligibility Employment
Citizenship: U.S. Citizen Participant Has One or More Disabilities
Courses which the applicant may be interested

College Grade Level
E-mail Comments
DD214 Request (SF180) Income Statement
LES (Leave & Earning) "Active Duty Only"

 Application/Interview
Student’s Last Name    
Student’s First Name
Student’s Middle Initial
Student’s Date of Birth
Gender Male Female Unknown
Race/Ethnicity Unknown
American Indian/Alaskan Native
Asian
Black or African American
Hispanic or Latino
White
Native Hawaiian or Other Pacific Islander
More than one race reported
Eligibility Unknown
Low-income and first-generation
Low income only
First-generation only
Recruitment Unknown
Referral from community agency
Referral from veterans’ agency
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Project’s Web site
Referral from educational institution
Word of mouth/walk-in
Referral from another TRIO project
Referral from non-TRIO program
Other
Educational Status
(at time of first entry into project)

Unknown
High school dropout
High school graduate
GED/high school equivalency credential recipient
High school graduate with some college
GED/high school equivalency with some college
Employment Status
(at time of first entry into project)		 Unknown
Unemployed
Employed part time
Employed full time
Retired
Participant Has One or More Disabilities Unknown
Yes
No
College Grade Level
(as of the beginning of academic year 2006–07)		 Unknown or no longer tracking
Accepted into postsecondary
1st yr., never attended
1st yr., attended before
2nd yr./sophomore
3rd yr./junior
4th yr./senior
5th yr./other undergraduates
On leave of absence after enrollment in a program of postsecondary education
Enrolled in graduate degree program
Degree or certificate completed; not enrolled
Completed Associate’s Degree; enrolled in 4-yr. institution
Not applicable, left program of postsecondary education before completion
Not applicable, not completed the educational program offered by the project
Not applicable, completed educational requirements for postsecondary
 
 

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