This document is an application for CUNY At Home in College Student Ambassadors. It requests contact information from applicants, including name, address, phone numbers and email. It asks for student information like high school attended, intended college and major. It contains questions about enrollment status, employment, citizenship and income eligibility. It provides 2015 poverty guidelines and allows applicants to describe themselves and why they want the position.

1. CUNY At Home in College
Student Ambassador Application
Part I: Contact Information
Name: _______________________________________________________________________________
Home Address: ________________________________________________________________________
Home Phone Number: ___________________________ Cell Phone Number: _____________________
Email Address: ________________________________________________________________________
Part II: Student Information
High School: __________________________________________________________________________
College Attending in Fall 2015: ___________________________________________________________
Intended Major: _____________________ High School GPA (Please Attach Copy of Transcript:_______
Part III: Please circle YES or NO to the following questions:
Are you enrolling in a full-time schedule? YES NO
Are you currently working? YES NO
Are you a citizen, resident alien, or do you have a visa that allows you to work? YES NO
Does your family have a gross adjusted income under 200% of the federal poverty guidelines? (See chart
on the following page) YES NO
Do you have a bank account (for direct deposit purposes only)? YES NO
Part IV: Tell us about yourself.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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Part V: Briefly explain why you want this position.
_____________________________________________________________________________________
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2. CUNY At Home in College
Student Ambassador Application
Income Eligibility Guidelines
You are eligible to a Student Success Leader if your adjusted gross family income falls at or below 200%
of the Federal Poverty Guidelines, which are updated annually by the United States Department of
Health and Human Services (HHS). http://familiesusa.org/product/federal-poverty-guidelines.
2015 Poverty Guidelines
Persons in family/household Poverty guideline
1 $23,540
2 31,860
3 40,180
4 48,500
5 56,820
6 65,140
7 73,460
8 81,780
For families/households with more than 8 persons,
add $4,160 for each additional person.
Acceptable Forms of Income Documentation: tax returns for the previous year, current pay stubs or
earnings statement from employer(s), public assistance, unemployment, social security or disability
award letters, child support cancelled checks or award letters, or dividend statements. In the event that
an applicant does not have any of the above documentation, a notarized letter documenting family
income source and amount may be submitted.
Any change in family circumstances that impacted income since the prior year may be detailed in a
letter. Examples of changes in circumstances include job loss by a major wage earner; divorce of
parents or you from a spouse; birth or adoption of a child; death or disability of a major wage earner;
loss of other income or benefits (such as Social Security or child support), by you, your parents or
spouse.