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State of New Jersey * Higher Education Student Assistance Authority * PO Box 540 * Trenton, NJ 08625-0540

October 1, 2013
(Fall and Spring Term)


Applicant Information (print and complete in ink)

March 1, 2014
(Spring Term Only)

1. Name: ___________________________ _____________________ __________


2. Gender: male __ female__

3. Race/Ethnicity: Please review text below and enter a number: _______ (See reverse for further information.)
1) Black, 2) Hispanic, 3) Asian American or 4) American Indian or Alaskan native

4. Social Security Number: __ ___ ___ - __ ___ - ___ ___ ___ ___ 5. Date of Birth: ______/______/______ 6. Current School Student ID Number: __________________________

7. E-mail: ________________________________________________ 8. Permanent Address: _______________________________________________________________________________



9. Phone: ______-- _____--_______


9. Date you began living in New Jersey: ______________

10. Date of high school graduation or date of GED: ________________________ 11. New Jersey county college you are or will be attending: _________________________________________________
(See list of eligible colleges on reverse)

12. Applicant year in program:



13. Name of certificate program in which you are currently enrolled or plan to enroll: __________________________________________________ (See list of eligible certificate programs on reverse)

Certification and Signature

I certify that the information furnished on this application is accurate and complete to the best of my knowledge. Applicant's Signature ___________________________________ Date _____________________

email to or see reverse for more information.

General Information
Award Payment and Renewal After classes start, HESAA will send half of your total annual award to your college. This payment is made after HESAA receives confirmation of your enrollment. In most cases, the college will defer payment of the amount of the award on your term bill. If your term bill does not reflect the award, contact the college. The second half of your annual award will be disbursed in the following term. The award is renewable for one year, depending on the availability of future SDA funds. To renew for a second year, you must continue to meet all eligibility requirements: 1) file a FAFSA within established State deadlines; 2) enroll at a New Jersey county college; 3) demonstrate financial need (NJEI below 10,500); 4) maintain satisfactory academic progress; and 5) complete application.

Eligible New Jersey County Colleges

Atlantic Cape Community College Bergen Community College Brookdale Community College Burlington County College Camden County College County College of Morris Cumberland County College Essex County College Gloucester County College Hudson County Community College Mercer County Community College Middlesex County College Ocean County College Passaic County Community College Raritan Valley Community College (Hunterdon and Somerset counties) Salem Community College Sussex County Community College Union County College Warren County Community College

NJ-GIVS Eligible Certificate Programs

The certification programs listed are just a sample of some of the programs that may be available, please check with the community college you wish to attend for more information. Architectural Building Construction Technology Architectural Engineering Technology Building Construction Technology Civil Construction Engineering Technology Civil Engineering Technology Computer Aided Drafting and Design Technology Construction Management Technology Construction Supervision Construction Technology Electronics Engineering Technology Engineering Engineering Science Engineering Technology Environmental Control Technology Fiber Optic Technical Specialist General Engineering Technology Heating/Refrigeration/Air Conditioning/Ventilation Industrial Technology Landscape/Design/Build Network Engineering Technology Quality Assurance Technology Solar Energy Technology Surveying Technology Sustainable Energy Technology

If you need additional information or help to complete this form, call 1 609 584 4480 Monday through
Thursday, 8 a.m. to 8 p.m. Friday 8 a.m. to 5 p.m., or visit our website at

Sign and date and mail completed application to: NJ HESAA, P.O. Box 540, Trenton, NJ 08625-0540 or email to

Penalty for False Information

If you qualify for State student financial assistance by purposely reporting false or misleading information, you shall be guilty of a crime of the fourth degree.
According to N.J.S.A. 52:18A-240 the Schools Development Authority (SDA) must set aside a portion of its construction contracts' revenue to train women and minority group members in construction trade occupations. Hence, to be eligible for the NJ-GIVS program, as it is funded through these "set aside" funds, recipients must be women or members of minority groups. As defined at N.J.A.C. 17:46-1.2 Minority means a person who is: 1) Black, which is a person having origins in any of the black racial groups in Africa; or 2) Hispanic, which is a person of Spanish or Portuguese culture, with origins in Mexico, South or Central America, or the Caribbean Islands, regardless of race; or 3) Asian American, which is a person having origins in any of the original peoples of the Far East, Southeast Asia, Indian Subcontinent, Hawaii or the Pacific Islands; or 4) American Indian or Alaskan native, which is a person having origins in any of the original peoples of North America.

HESAA Only Box: Eligibility Verification Funding for Women & Minorities County College FAFSA Completed NJEI Index of 10499 or less NJ HS Diploma or GED College SAP Requirement NJ State Grant Residency Requirement