St. James Gate Travis Theriault Memorial Scholarship

Application Form

Details of Applicant

Name: ______PH: ______SIN No.______

Address: ______City/Prov. ______Postal Code:______

Course Enrolled in:

Institution at which you are currently enrolled:

I have read and understand the rules and procedures of the St. James Gate Travis Theriault Scholarship. All the information contained in this application is accurate and contains no false statements.

Applicant’s Signature:______Date:______

Instructor reference

Name: ______Title:______

Address______City/Prov.______Postal Code:______

Institution at which you teach:

Please include the length of time you have known the applicant. How you would rate in terms of other Students in the same year, their attitude and general application to their studies.

Comments:

Instructor’s Signature ______Phone Number: ______Date:______

St. James Gate Travis Theriault Memorial Scholarship 206 Centennial Drive Moncton NB E1E 3Y2 Phone: 382-6110 Fax: 382-6110 E-Mail: [email protected]