Home Address: Street City State Zip Code
SS# : Gender: M F Date of Birth: Phone: Parent Address: Phone: I am an enrolled tribal member. My mother is an enrolled tribal member. My father is an enrolled tribal member.
(Check all above that apply, you MUST check at least one.) List the New York State Tribe/Reservation above members are enrolled in:
Name/Address of the
High School or College you attended: H.S. Graduation or GED Date: Latest College Semester:
Name/Address of the
College you will attend: Date of Acceptance: Date you begin College: # Credits This Semester:
(Full-time is at least 12 credit hours. If you dont know the exact # of credits, but know it will be full time, indicate such.) Program Type: 1 Year 2 Year 4 Year Other (please list) Anticipated Award Amounts: Full-Time (12 credits minimum) $1,000.00 / semester
Part-Time (less than 12 credits) prorated at $85.00 per credit
Part Time Examples: 3 credit hours $255.00
6 credit hours $510.00
9 credit hours $765.00
THE FOLLOWING FILING DEADLINES (postmark) ARE STRICTLY ADHERED TO:
Fall Semester: July 15 Spring Semester: December 31 Summer Session: May 20
Carefully read and complete BOTH SIDES of this application. Students are urged to keep copies of all correspondence with this office!
The Following Papers MUST Accompany This Application:
1. Official transcript of high school credits; OR a copy of an Equivalency Diploma; OR an official statement of enrollment in a special degree granting program, OR a college transcript if you have completed one or more semesters at the college level. The document submitted should clearly indicate the date of successful completion of High School.
2. Official tribal certification form. Enrollment cards WILL NOT be accepted.
3. If the applicant is under 18 years of age, the signature of the parent is required approving the educational plans of the student and assuring full cooperation, guidance and encouragement of the student in his or her educational career.
4. Letter of acceptance from the college of attendance.
5. On an attached sheet of paper, in typewritten form, a description of your educational goals and plans. Applications submitted without the student’s educational plans will be returned. This application and the above items should be submitted as one packet when possible, not separate pieces of correspondence. Postmark your packet, BEFORE THE DEADLINE listed on the front, to: New York State Education Department
Native American Education Unit
Room 475 EBA
89 Washington Ave
Albany, New York 12234 Students must request aid EACH and EVERY semester they wish to receive it, indicate the number of credits they will be taking, and submit their previous semester's grades. Students must request aid before the deadline and should not wait for their semester grades to do so. Grades may be submitted as soon as they are received.
Information provided on this form will be maintained in a file by the Native American Education Unit of the New York State Education Department. The Coordinator of the Native American Education Programs, Room 461 EBA, State Education Department, 89 Washington Ave, Albany, New York, 12234, (518) 474-0537, is responsible for the maintenance of these records. This information will be used to identify Native American students who are funded under the New York State Native American Post-Secondary Grant-in-aid Program. This information will be shared with tribal higher education offices and/or Native American tribal representatives working with higher education; higher education institutions personnel who are interested in the recruitment, admission and retention of Native American students at the undergraduate levels; and also with those institutions interested in recruiting Native Americans in opportunities for further education, scholarships, or professional training; and it will be used to recognize the degrees earned by Native Americans to share with prospective employers that may be known to the coordinator of Native American Indian Education Programs.