2018-2019 Identity/Statement of Educational Purpose Worksheet
Student’s Full Name: GTCC ID:
Instructions: You must appear in person at GTCC to verify your identity by presenting a valid government-
issued Photo identification (ID). Examples of accepted forms of ID are listed in section A below. The
institution will maintain a copy of your photo ID that is annotated with the date it was received and the name
of the official at GTCC authorized to collect the student’s ID.
Signature Requirement:
You must sign, in the presence of the GTCC official, the statement in section B, or.
If you cannot appear in person, you must send us a readable photocopy of the acceptable Photo ID,
and you must sign, in the presence of a notary, the statement in section B.
A. Verification of
Government Issued ID (Notary, check which document is copied for review)
☐ Driver’s License ☐ Non-Driving State ID ☐ Passport
B. Signatures(s)
I certify that I, (Print Student’s Name)
am the individual signing this
Statement of Educational Purpose and that the federal student financial assistance I may receive will only be
used for educational purposes and to pay the cost of attending GTCC for 2018-2019.
STUDENT SIGNATURE: DATE:
GTCC STAFF MEMBER SIGNATURE: DATE:
Please return this completed form to: GTCC Financial Aid Office, PO Box 309, Jamestown, NC 27282
This form cannot be faxed or scanned.
Financial Aid Office P.O. Box 309
Phone: 336.334.4822 Option 3
Jamestown, NC 27282
Fax: 336.217.8468
Notary’s Certificate of Acknowledgement
State of
City/County of /
On (Date) , before me (Notary’s Name), ,
personally appeared (Printed name of signer),
and proved to me on the basis of satisfactory evidence of identification (indicated in
Section A above) to be the above-named person who signed the foregoing
instrument.
NOTARY SIGNATURE (If applicable) DATE
Notary Stamp or Seal
My commission expires on the following
date:
Phone
:
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signature
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