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Get Plattsburgh State University Star Program Intake Form

STAR PROGRAM Intake Form Dear Potential STAR Student The STAR Program has been in operation on the SUNY Plattsburgh Campus since 1986. During that time it has given hundreds of young men and women the opportunity to attend college and experience a program structured for their success. We hope that you take advantage of this opportunity to join our family. Please fill out the information below to help us better serve you in the program* We look forward to meeting you. Sincerely Michele Carpentier STAR Program Coordinator Student Name Date of Birth MM/DD/YYYY Student Address Street City State ZIP Code Student s Phone Number Home Phone Number Cell Phone Number Parent s Name s Parent s Address Parent s Phone Number PLEASE ANSWER EACH OF THE FOLLOWING Are you a U*S* Citizen or the holder of an Alien Resident Card Y N Do either of your parents have a 4-year college degree Do you have a physical or learning disability Have you applied for financial aid How many individuals reside in your household What was your parents adjusted gross income for 2012 Student Signature Date Signed. During that time it has given hundreds of young men and women the opportunity to attend college and experience a program structured for their success. We hope that you take advantage of this opportunity to join our family. Please fill out the information below to help us better serve you in the program* We look forward to meeting you. We hope that you take advantage of this opportunity to join our family. Please fill out the information below to help us better serve you in the program* We look forward to meeting you. Sincerely Michele Carpentier STAR Program Coordinator Student Name Date of Birth MM/DD/YYYY Student Address Street City State ZIP Code Student s Phone Number Home Phone Number Cell Phone Number Parent s Name s Parent s Address Parent s Phone Number PLEASE ANSWER EACH OF THE FOLLOWING Are you a U*S* Citizen or the holder of an Alien Resident Card Y N Do either of your parents have a 4-year college degree Do you have a physical or learning disability Have you applied for financial aid How many individuals reside in your household What was your parents adjusted gross income for 2012 Student Signature Date Signed. During that time it has given hundreds of young men and women the opportunity to attend college and experience a program structured for their success. We hope that you take advantage of this opportunity to join our family. Please fill out the information below to help us better serve you in the program* We look forward to meeting you. Sincerely Michele Carpentier STAR Program Coordinator Student Name Date of Birth MM/DD/YYYY Student Address Street City State ZIP Code Student s Phone Number Home Phone Number Cell Phone Number Parent s Name s Parent s Address Parent s Phone Number PLEASE ANSWER EACH OF THE FOLLOWING Are you a U*S* Citizen or the holder of an Alien Resident Card Y N Do either of your parents have a 4-year college degree Do you have a physical or learning disability Have you applied for financial aid How many individuals reside in your household What was your parents adjusted gross income for 2012 Student Signature Date Signed. .

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