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

No

Email Address:

Gender

Female

Male

U.S. Citizen

Are you a U.S. Citizen?

Yes

No

If no, are you a permanent resident?

Yes

No

If yes, list alien number

Ethnicity and Race

Are you Hispanic/Latino?

Yes

No

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

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

No

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

Yes

No

Do you have a documented learning or physical disability?

Yes

No

Will you apply for financial aid?

Yes

No

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

Do you participate in a TRIO Educational Talent Search Program?

Yes

No

Family Information

What is your marital status?

What is your family size?

Are you a dislocated worker?

Yes

No

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

Yes

No

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

Yes

No

What is your family's annual taxable income?

Career Interests Profile and Assessment

Rank the categories from 1-6 to describe the occupational preferences most like you with 1 being your favorite:

Academic Profile and Assessment

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

Services Needed

What other services are you interested in?

Release of Records and Information Agreement

I affirm that all of the information provided is true and accurate to the best of my knowledge. I understand that I will be provided with services that will help me plan and complete my educational goals. In addition, I authorize the Educational Opportunity Center/Student Support Services Office to request, obtain and release financial aid, enrollment and/or disabilities records at Mercer University in order to provide services and generate reports. I also give permission for the use of my name and/or photograph for editorial, promotional, recruitment and educational purposes. All information is confidential except where University and federal regulation mandate.

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

Date:

Application for Services

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