Mississippi Car Tag Stipend Student Information Form Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * Mississippi Nursing License Number (If Applicable) Nursing Car Tag License Plate number School of Nursing in which you are enrolled Program of study Anticipated date of graduation MM DD YYYY Are you currently licensed as an RN in Mississippi? Yes No If so, do you work? Yes No Name of Employer? Are you receiving additional funding? Yes No If Yes, from? Mississippi Nurses Foundation or Mississippi Nurses Association Activities School Activities Community Activities Awards & Honors Thank you!
