Today's Date: (mm/dd/yy)

Last Name:

First Name:

Middle Initial:

Married Name:

Email Address:

Are You a South Carolina Resident?:

Yes 
No 

Permanent Mailing Address:

City/State/Zip:

Home Phone, Include Area Code:

Cellular Phone, Include Area Code:

Undergraduate Major:

Undergraduate Minor OR Dual Major:

Year Graduated w/Baccalaureate:

Are You Enrolled In Graduate School?:

Yes 
No 

Graduate School Enrollment Status:

Full Time (9+ Credits) 
Part Time (6 - 8 Credits) 
Less Than Part Time (5 or Less Credits) 

Graduate School Credits Earned YTD:

Most Recent Degree Completed:

Bachelor's 
Master's 
Doctorate/PhD 

Graduate School Institution:

Graduate School Program/Major:

Graduate School Year Graduated:

Are You Currently Employed?:

Yes 
No 

Who Are You Employed By?:

What Is Your Job Title?:

Work Phone Include Area Code:

Ethnicity:

American Indian or Alaskan Native 
Asian 
Black or African or American 
Hispanic or Latino 
White 
Native Hawaiian or Other Pacific Islander 
More Than One Race Reported 

Types of TRIO Support That
Helped You To Succeed In College:

Academic Counseling 
Campus Exposure 
Career Counseling/Exploration 
Computer Assistance 
Cultural Exposure 
Financial Aid Counseling 
Graduate School Counseling 
Math Assistance 
Personal Counseling 
Study Skills 
Time Management 
Transfer Counseling 
Tutoring Services 
Writing Assistance 
None Of The Above 

Please provide a comment or
program improvement suggestions: