Project Success Application – Great Bay Community College

Home > Project Success Application

Name*
Date
MM slash DD slash YYYY
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone (Home)
Phone (Work)
Phone (Cell)
Student ID#
E-Mail Address
High School Attended
Date Graduated
MM slash DD slash YYYY
G.E.D. Received:
Place
Date
MM slash DD slash YYYY
Number of years at this college
- Freshman
- Senior
Any other college experience?
- Yes
- No
Major
- Associates Degree
- Certificate
- Diploma
Expected Date of Graduation
MM slash DD slash YYYY
Credits Registered for this Semester
Have you participated in Project Success before?
- Yes
- No
If yes, when?
Check all that apply
- Single Parent
- Divorced
- Separated
- Never Married
- Widowed
- Displaced Homemaker (defined as an individual who has worked primarily without pay to care for a home and family, and for that reason, has diminished marketable skills and has been dependent on the income of another family member but is no longer supported by that income, and who, being either unemployed or underemployed, is having difficulty obtaining or upgrading employment.)
Number of Children Living With You
Name Age
Number of Adults Living With You
Name Age
Child Care Arrangements
Name of Day Care
In what town?
Number of Hours Per Week Children are in Day Care
Cost to You Per Week for Day Care
Income Per Month
- TANIF __________________________
- Social Security __________________________
- Food Stamps __________________________
- Medicaid/Medicare __________________________
- Housing Assistance __________________________
- Unemployment __________________________
- Transportation Assistance __________________________
- Child Care Assistance __________________________
- Child Support __________________________
- Alimony __________________________
- Wages __________________________
- Other __________________________
Total Income Per Month
Expenses Per Month
- Rent/Mortgage __________________________
- Utilities (phone, electricity) __________________________
- Food __________________________
- Transportation __________________________
- Insurance __________________________
- Medical/Dental Care __________________________
- Clothing __________________________
- Childcare __________________________
- Other __________________________
Total Expenses Per Month
BALANCE (Total Income LESS Total Expenses)
This application will not be considered for funds if it is not signed. If, at a later date, the above information is found to be false, it will be grounds for dismissal from the Project Success program.
By signing I verify that to the best of my knowledge, the above information is true.
Signature
Date
MM slash DD slash YYYY
Please return application to:
Jody Mancini
Project Success Coordinator
CAPS Department, Room 210K
Great Bay Community College
320 Corporate Drive, Portsmouth, NH 03801
Phone: 603-427-7724

Tel: 603-427-7600 |1-800-522-1194
Fax: 603-334-6308
[email protected]

Portsmouth Campus (Main)
320 Corporate Drive
Portsmouth NH 03801
Directions & Hours

Rochester Campus
5 Milton Road, Unit 32
Rochester NH 03867
Directions & Hours

Name	Age

Name	Age