111028_sss_application_911_0

St.
John’s University Student Support Services General Application

Instructions: Please complete items 1-10, sign and date your completed application before you submit it. If you
provide us with all of the required information you can expect a decision on your application within 7-10 business
days. Please print clearly.
1. Biographic Information
✗03631264
X Number: _____________________ 12182003 Gender: Male/Female
Birth date: ____/____/______
0
Palermo Matteo
Name: ______________________________________ Local Phone: _________________________
-
Last First Initial

µ
3't 3841st it apt IE
Address:_____________________________________
-
646-429-2551
Cell Phone: __________________________
Street
LIC NY 11101
____________________________________________
City State Zip
[email protected]
E-mail: __________________________
Campus/Off Campus Address:
Same as home address
___________________________________________________________________________________
2. Ethnic Background: What is your ethnicity? Please circle all that apply:
African American Native American Latino Asian c- Caucasian Other____________________
3. Citizenship: Please circle one: ☐

U.S. Citizen Yes No Permanent Resident of the U.S.? Yes No
Have a Student Visa? Yes No
4. Parent’s Education: Have either of your parents/guardians received a bachelor’s degree? Yes No 0
Associate’s Degree? Yes No
2 Family Income $___________________

5. Family Income: Size of Household (including yourself)______ 26,000
**Income verification may be required from the parent(s)/guardian(s) of dependent applications as well as independent applications.
0
6. Disability Status: Do you have a documented physical or learning disability? Yes No If yes, please explain
in detail:
_______________________________________________________________________________________
clinical Sciences
7. Academic Plans: Please list your current major or intended major of study:___________________________ Laboratory
Charles Pizzo
8. Educational Progress: Academic Advisor________________________
gaz ,
Semester/year admitted to SJU:___________________ 25
Estimated Graduation date from SJU:_______
Would you like to have a peer mentor? Yes

0
No
9. Services Needed: Please circle all areas for which you may need assistance:
÷
Course selection Math Skills Academic Counseling Resume Writing
Deciding on a college major Reading Skills Personal Counseling Interviewing Skills
Tutoring
College Survival Skills
Writing Skills Financial Aid Counseling
Test-Taking Skills Career Counseling i Life Planning
Social Networking
Other:___________________________________________________________
10. General Information:
Are you employed? Yes No

O If so, how many hours per week do you work? 1-10 10-20 20-30 Full-Time
O
Are you receiving financial aid at this time? Yes No If not, do you plan to apply in the future? Yes No
Do you intend to continue your education after graduation? Yes No O

If so, in what area of study?_____________________________________________________________
Clinical Lab Sciences

If not, in what field would you like to work after graduation?___________________________________
in a lab in
working
What do you see yourself doing five years from now?______________________________________________
_________________________________________________________________________________________
a
hospital
In your own words, please explain briefly why you want to participate in the Student Support Services Program:
When email excellent
I
got the benefit
__________________________________________________________________________________________
it seemed like a
program , and
I I would from it
greatly
__________________________________________________________________________________________
think .
__________________________________________________________________________________________
I certify to the best of my knowledge that the information I have provided on this application is correct. I
authorize Student Support Services to verify the information I have given to qualify for the program and to
gather other data required to extend program services.
Matteo palermo
Signature________________________________________ 41412022
Date____________________
For Office Use
The Department of Education’s approved income limit for a family of____ is $________. AGI is_________
Student qualifies as LI FG PD does not qualify
Accepted? Yes No
Rationale (if ineligible)___________________________________________________________________
______________________________________________________________________________________
_________________________________________ ____________________________________________
Application Reviewer’s Signature and Date Program Director’s Signature and Date

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St.

John’s University Student Support Services General Application

Last First Initial

3. Citizenship: Please circle one: ☐

2 Family Income $___________________

Would you like to have a peer mentor? Yes

Are you employed? Yes No

Do you intend to continue your education after graduation? Yes No O

Clinical Lab Sciences

For Office Use

Student qualifies as LI FG PD does not qualify

Rationale (if ineligible)___________________________________________________________________

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