Act 101 Program Application

Educational Information

Year of High School Graduation:

Do you have a GED?

Yes No

What is your major?

When did you first enroll at CCAC?

This application is filled out to the best of my knowledge. I understand that any information that I share with Act 101 will be kept strictly confidential according to the rules and policies of the college. I authorize Act 101 to release information to PHEAA, Act 101 Program. I hereby authorize permission for the ACT 101 office of the Community College of Allegheny County to release information concerning me as requested by the program. This includes, but is not limited to, student accounts, attendance, financial aid, registration, records and transcript information, and other information related to my enrollment at this institution. I also authorize the release of information, as requested, to the Act 101 program as requested by the ACT 101 staff. Student Signature:

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Use your mouse or finger to draw your signature above

Date

Application

Demographic

Educational Information