734 Salisbury Road · Statesville, NC 28677

P 704.878.9980 · F 704.878.9961 www.iredellsmartstart.org

_________________________________________________________________________________________2019-2020

EDUCATION AWARD APPLICATIONAll Education Award payments are contingent upon documentation of the applicant’s eligibility and the availability of funds. The deadline for completed applications is May 29, 2020. No documentation will be accepted after this date. Award supplement levels to be determined.

Personal Information:

Name: ______________________________________________________________________________(Last) (First) (MI or Maiden)

Mailing Address: ______________________________/_______________________________________(Street, Apt. #, Route) (City, State, Zip)

Phone: (____) _______________________ Email: _________________________________

*************************************************************************************Current Employment Information:

Facility Name: ____________________________ Phone: (____)_______________________

Position: _______________ Ages of children you serve: ________ Hours worked per week: _______*************************************************************************************Current enrollment:

Where are you enrolled (community college/college, university): _______________________________

Number of courses applying for (list only those from July 1, 2019-May 15, 2020): _________________

Number of credits applying for (list only those from July 1, 2019-May 15, 2020): __________________

Degrees expected to/earned between July 1, 2019 and May 15, 2020:

___Associate in Early Childhood ___ Bachelor in Early Childhood/B-K

************************************************************************************Please submit the following items with this application, if applicable:

o Official transcript or original student grade sheeto Pay stub or self-certification form if self-employed (to reflect hours worked per week) o Verification of placement test and/or its equivalent (new applicants only) o Completed professional development plan (updated annually)o W-9 form (new applicants/name changes only)

I certify that all of the above information is accurate. I understand that submitting false information on this application may result in permanent removal from participation in the Education Award program. Award supplement levels to be determined.

________________________________________________________________Working in partnership with:

734 Salisbury Road · Statesville, NC 28677

P 704.878.9980 · F 704.878.9961 www.iredellsmartstart.org

_________________________________________________________________________________________Applicant’s Signature ____________________________________ Date ____/____/____

Month Day Year

________________________________________________________________Working in partnership with: