Thank you for your interest in our Student Support Services program!  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 651-779-3226.

Personal Data: All information will be held in strict confidence in compliance with the Family Educational Rights and Privacy Act
First Name: *
Last Name: *
Middle Name:
Date of Birth: *
Century Student ID #
Address: *
Address 2:
City: *
State: *
Zip Code: *
Cell Phone Number:
Home Phone
Email Address: *
What is your gender? *
Marital Status
Citizenship Status *
Are you Hispanic or Latino (regardless of race)?
How's your academic standing?

Income Eligibility
Are you receiving financial aid?
For financial aid purposes, are you considered DEPENDENT (under 24, single, with no children is considered dependent) or INDEPENDENT? *
How many family members are in your household? *
Select the range that your 2020 family taxable income falls in *
List the names and ages of any children in your household
Parent Education  Indicate the highest level of education completed by your parents
Parent 1 *
Parent 2
If you were raised in a single-parent household prior to age 18 and that single parent did not receive a 4-year degree, check here.
Student Disability Information
Are you registered with or receiving disability services through Century’s Access Center? *
If yes, please identify your disability:
Student Educational History
Do you plan to receive a degree? If yes, what degree? *
Do you plan to transfer? *
Please list all other colleges and universities you have attended. Include dates and degree/diploma attained, if applicable:
Applicant's Personal Statement
Do you plan to be a full-time or part-time student? *
Briefly explain your educational and career goals. *
What help might you need to complete your goals? *
How can we help you complete your goals?  (check all that apply)
Time Management
Study Skills
Test Taking/Test Anxiety
Reading Comprehension
Note Taking
Math Skills
Sign and Submit:
Applicant Signature *
Please select a signature verification type.
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.