North Carolina Community Colleges
Golden LEAF Scholars Program – Two-Year Colleges
2020-2021 Student Application
Instructions: Complete this application and return the completed application to the college’s Financial Aid Office. 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
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, 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.
click to sign
signature
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