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.
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