North Carolina Community Colleges
Golden LEAF Scholars Program Two-Year Colleges
2019-20 Student Application
Instructions: Complete this application and return the completed application to the colleges Financial
Aid Office. Occupational Education students must also submit a copy of their transcript with the
application.
Personal Information:
Full Name: __________________________________________________________________________
Social Security Number: _______________________________________________________________
Home Address: ______________________________________________________________________
City, State, Zip Code: __________________________________________________________________
E-Mail Address: ______________________________________________________________________
Phone Number: _________________________ Mobile number: _________________________
NC County of residence: _______________________________________________________________
Length of residence in county: ____ less than 5 years ____ 5 10 years ____ more than 10 years
(To be eligible for this scholarship, your permanent residence must be in an approved NC county.)
Educational Information:
College you are attending: _____________________________________________________________
____ Occupational Continuing Education Student (must be enrolled in a credentialing program of at least
96 hours.)
Program you are enrolled in: _____________________________________________________
____ Curriculum Student: _____ GPA _____1
st
semester _____ not enrolled
Program you are enrolled in: _____________________________________________________
Other Information:
Have members of your immediate family worked for or owned a farming or agricultural related business
now or in the past? ____ yes ____ no
Have you or members of your immediate family been employed in traditional industries such as furniture,
textiles, or tobacco manufacturing? ____ yes ____ no
Has anyone in your household lost their job in the past two years? ____ yes ____no
Has anyone in your household transitioned from a full-time job to a part-time job? ____ yes ____ no
Please list all campus and community service activities you are currently involved in.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Use of Funds:
____ Tuition ____ Fees ____ Books ____ Supplies ____ Credentialing Exams
____ *Childcare _____ *Transportation
(* Students using funds for childcare and/or transportation purposes are asked to sign the statement(s)
below.)
I have read and understand the requirements for assistance. I hereby declare that the information provided
on this form is complete and correct to the best of my knowledge.
_______________________________________ ____________
Applicant’s Signature Date
Please return the completed application to the college’s Financial Aid Office.
Use of childcare funds statement: If selected for funding from the Golden LEAF Scholars Program
Two-Year Colleges, I certify that scholarship funds designated for childcare will be used exclusively while
I am attending class in order to fulfill my educational requirements.
_______________________________________ ____________
Applicant’s Signature Date
Use of transportation funds statement: If selected for funding from the Golden LEAF Scholars
Program Two-Year Colleges, I certify that scholarship funds designated for transportation will be used
exclusively for the purpose of supporting my travel to and from the college where I am enrolled for
educational purposes.
_______________________________________ ____________
Applicant’s Signature Date
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