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California St. Gainesville, TX 76240 Ashley or Stephanie Phone: 940-668-4242 Fax: 940-668-4260 E-mail: someone@example.com YES NO Have you been convicted of possessing or selling illegal drugs? *If no, stop here and sign below. YES NO 2. Did the offense for possessing or selling illegal drugs occur during a period of enrollment for which you were receiving federal student aid (grants, loans and/or work study)? *If no, stop here and sign below. YES NO Have you completed an acceptable drug rehabilitation program since your conviction? *An acceptable drug rehabilitation program must include at least two unannounced drug tests, and; be qualified to receive funds from a federal, state or local government or from a federally or state-licensed insurance company; or be administered or recognized by a federal, state or local government agency or court, or a federally or state-licensed hospital, health clinic or medical doctor. YES NO 4. Do you have more than two convictions for possessing illegal drugs? Only count convictions for offenses that occurred during a period of enrollment for which you were receiving federal student aid (grants, loans and/or work-study). YES NO Do you have more than one conviction for selling illegal drugs? Only count convictions for offenses that occurred during a period of enrollment for which you were receiving federal student aid (grants, loans and/or work-study).  _____/_____/_______ 6. Write the date of your last conviction for possessing illegal drugs here. If you have no convictions for possessing drugs, skip to question 8.  _____/_____/_______ 7. If you have only one conviction for possessing drugs, add one year to the date in question 6, and write that date here. If you have two convictions for possessing drugs, add two years to the date in question 6, and write that date here.  _____/_____/_______ 8. Write the date of your last conviction for selling illegal drugs here. If you have no convictions for selling drugs, skip to question 10. _____/_____/_______ 9. If you have only one conviction for selling drugs, add two years to the date in question 8, and write that date here. _____/_____/_______ Sign here: 10. Look at the dates you wrote in questions 7 and 9. If there is only one date, copy that date. If there are two dates, write the later one here. This is your  eligibility date . _______________________________________ DATE _________________ **Return completed form to the Financial Aid Office** Corinth Campus 1500 N. 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