Veterinary Scholarship Trust of New England

P. O. Box 3221

North Attleboro, MA 02761

SCHOLARSHIP APPLICATION

                                                    DATE________________________

APPLICANT’S FULL NAME (PRINT OR TYPE): ______________________________________

PLACE OF BIRTH: ___________________________DATE OF BIRTH:____________
                                

SOCIAL SECURITY NUMBER: __________________________________________________

PRESENT ADDRESS: ________________________________________________________

PERMANENT HOME ADDRESS:_________________________________________________

YRS. AT PERMANENT HOME ADDRESS: _________________________________________

NEW ENGLAND STATE OF RESIDENCE:__________________________________________

TELEPHONE:  PRESENT HOME: ________________PERMANENT HOME: _______________

VETERINARY COLLEGE ATTENDING: ___________________________________________

YEAR:  1_____2_____3_____4_____  

MONTH AND YEAR YOU EXPECT TO GRADUATE: _________________________________

HIGH SCHOOL OF GRADUATION: ______________________________________________________

CITY OR TOWN: ________________________STATE: ___________ZIP: _________

DATE OF GRADUATION: ________________________________________________

UNDERGRADUATE COLLEGE: ___________________________________________________________

DATE OF GRADUATION: ________________________________________________

IF YOU DID NOT GRADUATE FROM A NEW ENGLAND HIGH SCHOOL, ATTACH A LIST OF YOUR HOME ADDRESSES FOR THE 5 YEARS PRECEDING MATRICULATION INTO VETERINARY SCHOOL.

THE ABOVE-NAMED STUDENT IS IN GOOD STANDING AT THIS SCHOOL.

Signature, Veterinary School Official                             Title

School                                                                    Date

I AM ACQUAINTED WITH THE ABOVE NAMED VETERINARY STUDENT.

Signature, New England Veterinarian                                                Date                                         

_________________________________________________________________________

Address                                              

The information on this application is correct to the best of my knowledge.

_________________________________________________________________________

Applicant Signature                                                   Date

_________________________________________________________________________

Notary Public                                                           Date

MAIL COMPLETED APPLICATION TO THE ADDRESS ABOVE BY FEBRUARY 1,OF THE YEAR IN WHICH SCHOLARSHIP FUNDS ARE BEING REQUESTED.