PERM 44A-v (9/14/16)
V-SERF APPLICATION
Name: ____________________________________________________________ Date: _______________________
L Number: ______________________________________________________________________________________
Current Address: ________________________________________________________________________________
Major: ____________________________________________ Number of Credits this semester: _____________
Total Number of credits completed towards certificate or degree: _______________________________________
Home Telephone: _______________________________ Cell Telephone: _________________________________
Email Address: _________________________________________________________________________________
Academic Goals: ________________________________________________________________________________
Amount Requested: $ __________ ($1000 maximum)
Please provide details of why a one-time scholarship will provide the support needed to continue with your
academic goals. Attach documentation verifying the circumstances of emergency.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
We respectfully request if you are the recipient of the emergency funding that you provide a letter to the
Lehigh Carbon Community College Foundation including a short overview of how the funding will make a
difference in your educational pursuit. By signing this you are agreeing to provide the letter within 7-10
business days of receiving an email with your eligibility determination.
Student Name Date
OFFICE USE ONLY:
APPROVED: _______________________________________ DATE: _____________________________
APPROVED: _______________________________________ DATE: _____________________________
APPROVED: ________________________________________ DATE: _____________________________
