2013 STAR Program Application

First Name:  
Last Name:  
Address:  
City:  
State:  
Zip Code:  
Student Email:  
Date of Birth (mm/dd/yyyy):  
Student Telephone:  
Student Cell Phone:  
Parent/Guardian Phone:  
Student ID (do not include zeros):  
What do you plan to major in?  

Are you interested in: (check all that apply)
Biomedical and Health Professions
Education
Ethnic Studies
Honors
Hotel and Restaurant Management
Social and Behavioral Sciences

How did you hear about the STAR Program? (check all that apply)
Received a letter in the mail
High School Counselor
NAU Admissions Counselor
Discover NAU Event
Campus Visit
Attended Information Session in my area
Found it on the NAU Website
Dorrance Foundation/ACSF
Other (provide information below)

What is the highest educational level any of your parents/guardians* have achieved?
*Parents/guardians include biological, step, adoptive, etc. with whom you regularly resided or who supported you.










Parents' Financial Information

Parent(s) Income Information: If parents are divorced or separated, provide information for only the parent with whom you live with currently. If the parent whose information was used has remarried, stepparent information is required.
2011 Adjusted Gross Income (AGI): $ 
(from IRS form 1040 – line 37, 1040A – line 21 or 1040EZ – line 4)

2011 Father's (or step-father's) Income: $ 
2011 Mother's (or step-mother's) Income: $ 
(This may be on two W-2 forms or on IRS 1040 – lines 7, 12, 18 plus 14, IRS1040A – line 7 or 1040EZ – line 1)

2011 Federal Income Tax Paid: $ 
(from IRS1040 – line 55, IRS1040A – line 35 or IRS 1040EZ – line 11)

Parents' assets value: $ 
(stocks, bonds, cd's, cash, checking, etc.)

Parents' assets (other) value: $ 
(Business, farm, rentals, etc.)

Number in family:  
Number of children in college:  
Age of older parent/stepparent:  

Student Financial Information

2011 Student's Adjusted Gross Income (AGI): $ 
(from IRS form 1040 – line 37, 1040A – line 21 or 1040EZ – line 4)

2011 Student's Federal Income Tax Paid: $ 
(from IRS1040 – line 55, IRS1040A – line 35 or IRS 1040EZ – line 11)

Student's assets value: $ 
(stocks, bonds, cd's, cash, checking, etc.)

Student's assets (other) value: $ 
(Business, farm, rentals, etc.)

DISCLOSURE: By completing this form, you are stating that all of the information is true and correct to the best o f your knowledge. If asked by an authorized official, you agree to give proof of the information that you have provided on this form.

I agree to allow the STAR program and Northern Arizona University to use the provided information to research my university files to determine eligibility. I also understand that the submission of this form does not guarantee my selection for the program.

Student Electronic Signature (type full name):  

Date:


Submit  Reset

After clicking "Submit" you should receive a confirmation email. If you do not receive confirmation, please contact the STAR Program at STARProgram@nau.edu