Orlin & Nancy Herrild Veterinary Medicine Scholarship

Personal Information

First Name

Last Name

Address

City

State

Zip Code

Email

Cell Phone

Home Phone

Do you plan to return to the Marinette and Menominee Area after graduation?

Yes
No

Academic Information

Name of High School you graduated from

Veterinary School you are attending

Current GPA

Are you entering your 2nd or 3rd year of Veterinary School?

Yes
No

Are you a previous recipient of this scholarship?

Yes
No

Character and Fitness Requirements

Have you ever surrendered, resigned, canceled, or been denied a professional license or other credential in Wisconsin, or any other juridiction?

Yes
No

Provide details on an attached sheet, including the name of the profession and the agency and license number.

pdf files only

Is disciplinary action pending against you in any jurisdiction?

Yes
No

Provide details on an attached sheet about the pending action, including the name of the agency and status of the action.

pdf files only

Have you ever been convicted of a misdemeanor or felony, or do you have any felony or misdeamenor charges pending against you?

Yes
No

Please attach a sheet providing details.

pdf files only

Have you ever been convicted of a crime in connection with controlled substances under state or federal law, or been excluded or directed to be excluded from participation in a medicare or state health care program, or is any such action pending?

Yes
No

Please attach a sheet listing the date(s) of the incident(s).

pdf files only

Required Attachments

High School Transcript

pdf files only

College Transcript

pdf files only

I, the student applicant, attest that to the best of my knowledge the information provided is accurate.

Today's Date

Signature

You are not eligible to apply for this scholarship.

Contact Information