Middle Name:
Last Name:
Phone:
Permanent Mailing Address City, State Zip Code AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY (format: 55406 or 554061234)
Email Address
Racial background (select one or more)
American Indian or Alaska Native A person having origins in any of the original peoples of North and South America (including Central America) who maintains cultural identification through tribal affiliation or community attachment.
Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent.
Black or African American A person having origins in any of the black racial groups of Africa.
Native Hawaiian or other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
I give permission to my college and MOHE to verify the information provided on this application and to obtain information for all funding sources relating to this application.
I certify that the information on this application is true and correct and I promise to provide additional documentation if requested. I promise to provide a written report to MOHE of any changes.
I understand this form is used to establish eligibility for this program and that if I purposely give false or misleading information on this form, I may be subject to a fine, prison sentence or both; and such action may result in the forfeiture of future awards from this program.
I understand that any changes in my FAFSA, MN Dream Act Application, Pell Grant, MN State Grant, or other state or federal financial aid may cause my grant award to be adjusted.
I understand that all awards are subject to the availability of funds.
I certify that I have read and understand the Notice to Applicants section in the form instructions.
Applicant's Signature (type name): Date: 01/20/2021
Section 7(b) of the Federal Privacy Act of 1974 (5 U.S.C. 552a) requires that when any federal, state, or local government agency asks you to disclose your Social Security Account number, you must be advised whether that disclosure is mandatory or voluntary, by what statutory or other authority the number is solicited, and what uses will be made of it. The Social Security number will be used by the Minnesota Office of Higher Education (MOHE) to verify your identity, and as an identifier of your file in order to record necessary data accurately. As an identifier, the Social Security number is used in the Teacher Candidate Grant program for such purposes as processing the application form, program evaluation, and reporting. You are being advised that disclosure of your Social Security number is voluntary. However, failure to submit your Social Security number may prevent further processing of this form.
Pursuant to Minnesota Statutes, Sec. 13.04, subd. 2, you are hereby informed that the information supplied in this form may be used as follows: (1) in the processing and verification of the data supplied to determine your eligibility for this program; and (2) for compilation and analysis of summary data relative to this program. Private data, including identifying information, will not be disclosed under Minnesota Statutes, Sec. 13.32, unless otherwise stated by statute or at the request of the Legislative Auditor. You are not required to provide the information supplied in this form. However, failure to submit requested data may prevent further processing of this form. The information supplied in this form may be shared with other public and private individuals and entities in order to use the information for the purposes specified above.
The Office of Higher Education does not discriminate on the basis of disability in the admission or access to, or treatment or employment, in its programs or activities. This document can be made available in an alternative format to individuals by calling (800) 657-3866 or (651) 642-0567.
