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.
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signature
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