1 | P a g e
North Carolina Community Colleges
Golden LEAF Scholars Program Two-Year Colleges
2020-2021 Student Application - Due February 8, 2021
Instructions: Complete this application and return the completed application to the Financial Aid Office.
Do not email the application. Eligible students must reside in a rural county that is tobacco dependent,
or economically destressed, as determined by the Golden LEAF Foundation (Please see your school’s
financial aid office for a list of 2020-2021 Qualifying Counties).
Personal Information:
Full Name: _________________________________________________________________________
Student ID 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
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
2 | P a g e
Please list all campus and community service activities you are currently involved in, if any.
Use of Funds:
____ Tuition ____ Fees ____ Books ____ Supplies ____ Credentialing Exams
____ Childcare _____ Transportation
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.