Disability Services: Application Form

Name (first, middle initial, last)*

If married, what was your previous last name?

Address*

Street AddressAddress Line 2CityStateZip Code

Last 4 digits of Social Security Number*

Please enter a value between 0000 and 9999.

MaineStreet ID*

This is your Student ID number. If you don't know what yours is, contact the Office of Student Records at 207-768-9607

Date of Birth*

MM

DD

YYYY

Phone Number*

Email Address*

Taxable Income is Under*

Proof of Income*

Ethnic Background*

Are you a US Citizen*

Parents' Education*

Gender*

Disability*

Identify Disability*

Mental or physical disabilities, including learning disabilities

Have you ever participated in:

Upward Bound (UB)
Talent Search (TS)
Maine Education Opportunity Center (MEOC)

Check any that apply

Post Secondary Degree/Certificate Completed

Do you have financial aid or other types of assistance for the school year?*

From what sources?*

Check all that apply

Are you now or plan to be involved with any UMPI or local community club activities?

Examples: Sports teams or other local/community organizations such as PTA, church groups, town recreation sports teams, aerobic classes, adult ed, etc

Please list services that you are requesting*