Submit Your Application

Thank you for your interest in our Student Support Services program! To qualify you must be at least one of the following: low income and/or first generation and/or have a disability.

Please complete this application as thoroughly as possible.

You cannot save and restart this application.

You may want to review the included items, take some time to make notes and gather the required documents, and then return to submit your application.

If you have any questions, please call our office at (870) 391-3338.

General Information:

Northark ID Number

Last Name *

First Name *

Middle Name

Date of Birth *

Mailing Address *

Mailing Address Line 2

City *

State *

Zip *

Gender *

Home Phone

Cell Phone Number

Personal Email Address *

Northark Email Address

First-Generation College Student
A student, neither of whose natural or adoptive parents received a baccalaureate degree; or
A student whose sole custodial parent did not receive a baccalaureate degree.

Based on the above definition, are you a first generation student? *

Adjusted Gross Income

Line 11 on Tax Form 1040

Based on the above chart do you qualify as low income?

Disability

Do you wish to self identify as having a disability as defined by Section 504 Of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990?

Do you already have an associate or bachelor's degree? *

Are you a citizen or national of the U.S. or meet the residency requirements for Federal student financial assistance? *

Do you have a high school diploma or GED? *

Are you planning on transferring to a four-year college? *

Preferred Contact Method *

Ethnicity *

Race, choose one:

If someone told you about SSS, please list their name here:

Terms of Submission:
By submitting this application, you acknowledge that all of the above information is correct and accurate to the best of your understanding. You are also authorizing SSS to secure financial aid and academic information necessary to confirm eligibility (all personal information will be held in confidence by project staff and released only by your permission). You are also certifying that the taxable income you entered is accurate based on your latest tax return.

*

Please select a signature verification type.