ANSELMIAN STUDENT REFLIEF FUND
APPLICATION FORM
Student Name:
Student Identification Number:
Phone Number:
Email Address:
Please provide a brief statement explaining why you are requesting Student Relief
Funds. Please list the expense(s) and amount(s) for which you are requesting
assistance.
Please provide a brief explanation of your financial circumstances, and describe your
efforts to obtain funds through other sources.
Student Certification
By typing my name below, I certify that:
- The information is complete and accurate
- I will use the support from the Anselmian Student Relief Fund only for the purposes
specified above.
- I will reimburse Saint Anselm College if the funds, or some portion of the funds, are
no longer needed or if funding is provided to me from another source, e.g.,
insurance
- I will submit receipts or other documentation as requested
Name: ___________________________________ Date: ___________________
Students must provide receipts and/or documentation for payment or reimbursement
not later than 10 days after funds have been dispersed.
Please submit completed applications to studentrelief@anselm.edu.
