DD Form 2753 National Security Education Program (NSEP) Service Agree

NATIONAL SECURITY EDUCATION PROGRAM (NSEP)
SERVICE AGREEMENT REPORT (SAR) FOR SCHOLARSHIP AND FELLOWSHIP AWARDS

OMB No. 0704-0368
OMB approval expires
Dec 31, 2007

The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0368). Respondents should be aware that notwithstanding any other provision of law, no
person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

SEND THIS COMPLETED FORM BY MAIL, FAX, OR EMAIL TO:
National Security Education Program
P.O. Box 20010
Arlington, VA 22209
Fax: 703-696-5667
Email: [email protected]
For questions, call or email: (703) 696-1991; [email protected]

PRIVACY ACT STATEMENT
AUTHORITY: P.L. 102-183, David L. Boren National Security Education Act of 1991, December 4, 1991, as amended, DoDD 1025.2, and E.O.
9397.
PRINCIPAL PURPOSE(S): To monitor the award winner's progress toward fulfilling the service requirement of Boren Scholarship and Fellowship
recipients.
ROUTINE USE(S): In the case of a recipient in default of a service agreement, information may be disclosed to consumer reporting agencies to
report credit information; and to other governmental agencies or private organizations to facilitate collection of amounts owed the government.
Information is also subject to review through computer matching programs with other agencies to verify employment status and to help collect any
delinquent debt incurred as a result of the NSEP.
DISCLOSURE: Voluntary; however, failure to furnish the requested information may result in your being required to reimburse the U.S. Treasury
for the total cost of your scholarship or fellowship plus interest.

SECTION I - DEMOGRAPHIC DATA
1. RECIPIENT NAME (Last, First, Middle Initial)

2. FORMER NAME

3. SOCIAL SECURITY NUMBER

4. CURRENT CONTACT INFORMATION
a. STREET ADDRESS

b. CITY

c. STATE

f. HOME TELEPHONE NUMBER
(Include area code)

g. SECONDARY OR WORK TELEPHONE
NUMBER (Include area code)

b. CITY

c. STATE

NEEDS DD 67

e. E-MAIL ADDRESS

5. PERMANENT CONTACT INFORMATION
a. STREET ADDRESS

d. ZIP CODE

d. ZIP CODE

e. HOME TELEPHONE NUMBER (Include area code)

SECTION II - RECIPIENT'S STATUS
6. I have been engaged in work in fulfillment of my requirement during this reporting period.
(Complete Items 12 through 20 in Sections III and IV on the back.)
7. I have not graduated from nor terminated enrollment in the degree program pursued while receiving NSEP support.
My anticipated graduation date is (Month/Year)
. (Complete Items 17 and 20 in Section IV.)
8.a. I am furthering my education and request a deferral of the service requirement until I complete my
(Institution); my expected graduation date

degree program at
is (Month/Year)

. (Complete Items 17 and 20 in Section IV.)

b. I am furthering my education and do not request a deferral of the service requirement.
My anticipated graduation date is (Month/Year)

. (Complete Items 17 and 20 in Section IV.)

9. I have not obtained employment in fulfillment of my service requirement during this reporting period.
(Complete Items 17 and 20 in Section IV.)
10. I request a one year extension as the time for completing my service requirement has expired.
(Submit detailed plan outlining how you plan to fulfill your service requirement during the extension period.) (Complete Items 17 and 20
in Section IV.)
11. I request a waiver from my service requirement. (Explain grounds for waiver on a separate piece of paper and attach to SAR.
Please note that waivers are granted only in extreme cases. Also complete Items 17 and 20 in Section IV.)

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PREVIOUS EDITION IS OBSOLETE.

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SECTION III - DESCRIPTION OF SERVICE
12. DATES
a. FROM (MM/DD/YYYY)

13. NUMBER OF HOURS PER WEEK

14. TYPE OF EMPLOYMENT (X one)

b. TO (MM/DD/YYYY)

a. FULL TIME (30 hours/week)
b. PART TIME

15. SUPPLEMENTAL INFORMATION (X all that apply)
a. I use a foreign language in my position. (Explain:)
b. My position requires a security clearance. (If so, type:)
16. DESCRIPTION OF DUTIES (Please spell out all acronyms.)
a. DEPARTMENT/ORGANIZATION/INSTITUTION
b. OFFICE

c. TITLE

d. Describe the work you are doing to fulfill your NSEP service requirement and how it relates to U.S. national security. If you are eligible to work in
higher education and are doing so, describe the connection with your NSEP-funded study.

NEEDS DD 67
SECTION IV - CERTIFICATION (NOTE: Service will NOT be approved without supervisor verification and signature.)
17. I have activated and updated my resume on NSEPNET.

a. YES

b. NO

18. CONTACT INFORMATION FOR EMPLOYING ORGANIZATION
a. NAME OF EMPLOYING ORGANIZATION

b. SUPERVISOR'S TELEPHONE NUMBER (Include area code)

c. STREET ADDRESS

e. CITY

g. ZIP CODE

f. STATE

g. SUPERVISOR'S EMAIL ADDRESS
19. SUPERVISOR VERIFICATION
a. SUPERVISOR'S NAME (Last, First, Middle Initial)

b. TITLE

c. SUPERVISOR'S SIGNATURE

d. DATE SIGNED

20. I certify, to the best of my knowledge, that all of the above statements are true, complete, and correct. I agree to provide additional
information as requested. I understand that my service requirement is completed upon receipt of written notification from NSEP.
I agree to submit this form annually until my service is complete, or every six months if granted an extension. I will notify NSEP within
10 days if my contact information changes.
a. NAME

b. SIGNATURE

c. DATE SIGNED

b. SIGNATURE

c. DATE SIGNED

SECTION V - FOR NSEP USE ONLY
21. ACTION
22.a. NAME OF NSEP OFFICIAL

23. LENGTH OF
REQUIREMENT

24. MONTHS PREVIOUSLY
APPROVED

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25. APPROVED
MONTHS

26. MONTHS
REMAINING

27. YEAR OF
AWARD

28. (X)
S

LF

F

EHLS

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