Form 1049 Application for Designation as an Eligible Institution

UNITED STATES DEPARTMENT OF EDUCATION

WASHINGTON, D.C. 20202

APPLICATION FOR DESIGNATION AS AN ELIGIBLE INSTITUTION

FISCAL YEAR 2017

CFDA Number: 031H

To apply for grants under

Title III Programs SIP, ANNH, AANAPISI, NASNTI, HSI STEM, and PBI

Title V Programs HSI and PPOHA

Authority: 34 CFR Part 606 and 607 Programs

Important: You are required to provide the information requested

in order to obtain or retain a benefit.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.  Public reporting burden for this collection of information is estimated to average 7 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  The obligation to respond to this collection is required to obtain or retain benefit (34 CFR Part 606 and 607). Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to regulations.gov during the public comment period for this collection of information.  If you have specific questions about the form, instrument or survey, please contact: Institutional Service, U.S. Department of Education, 400 Maryland Ave. SW, 4^th Floor, Washington, DC 20202.

* This form must be completed electronically.

Part I. Identity of Applicant Institution

1. Institution/Campus OPE ID Number:

2. Name of Institution/Campus Requesting:

3. Address (Street # or P.O. Box and Street Name, City, State, Zip):

4. Contact Person’s Name: (Last Name, First Name, Middle Initial):

5. Contact Person’s Title, Phone Number, Extension:

6. E-mail Address:

7. Data Universal Numbering System (DUNS Number):

8. Type (mark one): ( ) Two-Year Institution ( ) Four-Year Institution

9. Control (mark one): ( ) Private Non-Profit Institution ( ) Public Institution

Part II. Institutional Enrollment

1. Total Institutional Enrollment (Fall 2014 Head Count):

2. Total Minority Enrollment (Fall 2014 Head Count):

Part III. Institutional Statistics

1. Needy Student Requirement

1. Fall 2014 Head Count Enrollment of Undergraduate and Graduate Degree Students:

B. Fall 2014 Recipients of Title IV Need-Based Financial Assistance:

(Include Only Pell Grant, Supplemental Educational Opportunity Grant, College Work Study, and Perkins Loan)

C. Fall 2014 Enrollment of Half-Time, up to and including Full-Time, Undergraduate Students:

D. Fall 2014 Pell Grant Recipients:

2. Core Expenses Requirement

A. Undergraduate Full-Time Equivalent Fall 2014 Enrollment

a. Total Full-Time Undergraduate Students:

b. Total Number of Credit Hours for all Part-Time Undergraduate Students:

B. Graduate Full-Time Equivalent Fall 2014 Enrollment:

a. Total Full-Time Graduate Students:

b. Total Number of Credit Hours for all Part-Time Graduate Students:

C. Total 2014-2015 Core Expenses:

D. Average 2014-2015 Core Expenses per FTE = C/(A+B):

Part IV. Specific Institutional Eligibility Requirements

1. Needy Student Requirement (mark A, B or C)

( ) A. According to the result, after dividing item 1B by item 1A in Part III of this form, at least 50% of Degree Students are recipients of Need-Based Financial Support; or

( ) B. According to the result, after dividing item 1D by item 1C in Part III of this form, our enrollment exceeds the pertinent threshold for Substantial Percentage of Students Receiving Pell Grants for the 2014-2015 year.

( ) C. Requesting Waiver (Section 607.3(b) and Section 606.3(b) option(s)):

Check an option, and attach the narrative justification to this form.

AND

2. Core Expenses Requirement (mark A or B)

( ) A. The Core Expenses per FTE Student are less than the pertinent threshold for base year 2014-2015.

( ) B. Requesting Waiver (Section 607.4(c) and (d) and Section 606.4(c) and (d) option(s)):

Check an option, and attach the narrative justification to this form.

Part V. Certification

(Although this Certification requirement is waived for applicants applying online,

the Department reserves the right to require a signed form on request.)

To the best of my knowledge and belief, all data in this application are true and correct. The governing body of the applicant has duly authorized this document and the applicant will comply with the required assurances. We meet the accrediting requirements and, if applicable, we meet the definition of a branch campus as defined in 34 CFR Part 606.7(b) and 34 CFR 607.7(e).

Authorized Representative's Typed Name and Title:

Date:

Authorized Representative's Signature:

Telephone Number:

Fax Number:

Former Name of Applicant:

Institution/Campus (if applicable)

Form Approved - OMB No. 1840-0103 Expiration Date xx/xx/xxxx

ED Form 1049 (Revised 11/99), Replaces ED Form 1049, Revised 8/95 which is obsolete.