Please complete the short application below and mail to:

Russell Scholars Program

37 College Ave

Gorham, ME 04038

Cut here ->

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First name                   MI                        Last name

______________________                     __________________________

Date of birth                                                 Home phone number

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Street Address

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City/Town                          State                     Zip        Country

_____________________                ______________________________

Year of High School Graduation         High School

____________________________         ___________________________

e-mail                                                              Cell phone