Form 1

Application for Participation in the National Health Service Corps Scholarship Program

0146 nhsc form 2007

Application for Participation in the National Health Service Corps Scholarship Program

OMB: 0915-0146

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0915-0146 can be found here:

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2008 NHSC SCHOLARSHIP APPLICATION HOMEPAGE
To apply for the NHSC Scholarship program you will need to register below and complete the online Application
Form as well as submit the application documents outlined in the Applicant Informaton Bulliten. The
online Application Form must be submitted by midnight on March 28, 2008.
In order for your application to be considered complete, you will need to submit the signed Assurances, the
signed Certification, and the supporting forms/documents outlined in the Applicant Information Bulletin.
Please see the Applicant Information Bulletin and the checklist for further information.

Fields marked with an * are required.
* Your Last Name:
* Your First Name:
Your Middle Initial:
* Street Address:

* City:
* State:
* Zip Code:
* Daytime Phone Number:

Discipline:
* Your Email Address:
* Reenter Email Address:

* Create Password:

Password must be at least 8 characters
long, and must include one character
from at least 3 of the following 4 types:

* Reenter Password:

1. Uppercase (A-Z)
2. Lowercase (a-z)
3. Numeric (0-9)
4. Symbol (~!@#$%^&*())

* Create Security Question:

* Create Security Answer:

Submit

Please enter the information below. If you experience any problems, please contact the HRSA Help Desk
at [email protected] or (800) 638-0824.

Scholarship Program: FAQs | Applicant Information Bulletin

Application System Login
Log in here if you are:
●

Completing your Scholarship Program application.

Note: Once you have completed the application and clicked "Submit", you will not be able to log
into the system or access your application to make changes. For information on the NHSC
Scholarship Program please call the help line at (800) 638-0824 between 8:30 AM and 5:00
PM, Monday - Friday Eastern Time or email us at [email protected]. For information
on the NHSC Loan Repayment Program or the NHSC Scholarship Program, please click here if
you need any further assistance.

Your Email Address:
(Please enter your full e-mail address in the form of
account@mailserver, for example:
[email protected])

Password:
Submit

Forgot your password? Click here.
Applying to the program and don't have a Password? Click here to apply.

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U. S. Department of Health and Human Services
Health Resources and Services Administration
Bureau of Clinician Recruitment and Service
Division of National Health Service Corps

FORM APPROVED:
OMB No. 0195-0146
Expiration Date
Click here to see the Public Burden Statement.

APPLICATION FOR NATIONAL HEALTH SERVICE CORPS (NHSC)
SCHOLARSHIP PROGRAM

The following is the online Application Form for the National Health Service Corps (NHSC) Scholarship Program. To
start your online Application Form, please click on Section A: Assurances and complete all requested information.
Once you have completed this section in its entirety, you will be asked to print and sign the form to submit with
your application documents. You will then need to save your information before moving on to the next section. The
system will prevent you from accessing the next section until you have completed prior section. You may log off and
complete the remaining forms at a later time. The online Application Form must be submitted by deadline indicated
in the Applicant information Bulletin.
You will be required to print the Certification form, sign it and submit a copy with your application documents once
you have completed all sections, you will have the opportunity to review your selections and print the complete form
prior to final submission. After carefully reviewing the Application Form, you should submit the form by clicking the
"SUBMIT" button on Section. The Application form is not considered complete until it is submitted. Please note:
Once you have submitted the complete application, you will not be able to login and access the form. Please make
certain you review the application carefully before submitting it and print a copy before exiting.
All required information must be completed for each section. Please see the Application Information Bulletin
for further information and instructions where noted.
Please note: This online form is only one part of the complete NHSC Scholarship Program Application. In order for
your application to be processed, you will also need to provide the forms and supporting documentation outlined in
the Applicant Information Bulletin. Additional forms and supporting documentation should be mailed to: National
Health Service Corps Scholarship Program, c/o Discovery Logic, 1375 Piccard Drive, Suite 360, Rockville, MD 20850
The online Application Form must be submitted by midnight on March 28, 2008. All supporting application
documents must be postmarked by deadline indicated in the Applicant information Bulletin.
Please refer to the Applicant Information Bulletin for the deadlines for the supporting documents.

STATUS
FORM
COMPLETED DATE
Section A: Assurances

Not Started

Section B: Eligibility

Not Started

Section C: General Information

Not Started

Section D: Degree Information

Not Started

Section E: Background

Not Started

Section F: Career Goals

Not Started

Section G: Certification

Not Started

LAST UPDATED DATE

PUBLIC BURDEN STATEMENT
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0146.
Public reporting burden for this collection of information is estimated to average 3 hours per respondent for the time
for reviewing instructions, searching existing data sources, 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 this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33,
Rockville, Maryland, 20857.

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SECTION A: ASSURANCES
After providing your responses to this section electronically, you will need to print this form, sign and date it,
and then submit it with your application materials. This assurance must be submitted with your
supporting documentation in order for your application to be complete. If you decline any assurance, the system
will not allow you to complete the online application.
In submitting this application, I certify that I understand that I should be offered and accept a NHSC scholarship:
●

I will provide primary care service in a NHSC approved site in a Health Professional Shortage Area for 1 year for
every every school year or partial school year of Federal support, with a minimum service of two years.
Accept

●

My services will begin immediately following graduation for the health professions training that is being paid for,
or approved residency where appropriate.
Accept

●

Decline

I will most likely serve as an employee of a community clinic or health center during my service obligation.
Accept

●

Decline

I will relocate consistent with the needs of the National Health Services Corps.
Accept

●

Decline

Further more, I understand that if I fail to meet the above service requirements, I will owe the United States
damages equaling 3 time the scholarship award plus interest, as calculated by the government.
Accept

Decline

** Please note applicants who indicate a decline response will not be considered as a viable candidate
for the National Health Service Corps and the electronic application will not allow them to proceed.
Instructions: Click Here to print this form. You must print and sign this form and mail it along with your
other application documents.
Click Here to Print this form

Submit

You will be automatically logged off the session due to system security controls, if you do not continue
to the next section within a 30 minute time period.

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SECTION A: ASSURANCES
You have indicated that you are not willing to accept the requirements for the National Health Service
Corps Scholarship program. Therefore, you will not be allowed to continue with the electronic
application.
Click here to log out

Click here to review the questions

You will be automatically logged off the session due to system security controls, if you do not continue
to the next section within a 30 minute time period.

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SECTION B: ELIGIBILITY
All fields marked with * are required.
1.

Are you an American Citizen?
(If you were born outside of the United States, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, the
Territory of Guam, the Territory of American Samoa or Swains Island, documentary proof of U.S. citizenship or
U.S. national status must be submitted with the application. This may consist of a copy of your birth certificate
that states your U.S. citizenship, the ID page of your U.S. passport, or a certificate of citizenship or
naturalization.)
Yes

*Have you ever been dismissed, placed on probation, suspended, or voluntarily withdrawn from a
health professions school for academic or disciplinary reasons?
Yes

If yes, please submit verification of acceptance or good standing from your current health professions school or program for the
upcoming school year.
3.

*Do you have a judgement lien against your property for a Federal debt?
(Applicants who have a court judgment entered against them for a debt owed to the United States which
creates a lien against their property are precluded from receiving Federal funds (including NHSC scholarship
awards), until the judgment lien has been paid in full or otherwise satisfied.)
Yes

*Have you ever been delinquent on a Federal debt, as defined as being more than 90 days past due
on a scheduled payment?
(Applicants who have a delinquent Federal Debt will not be selected for scholarship awards regardless of
circumstances.)
Yes

*Do you have an existing health profession service obligation?
Yes

*Will you be enrolled as a full-time student during the 2008-2009 school year and will your class
attendance begin on or before September 30, 2008?
Yes

No
Save & Continue

You will be automatically logged off the session due to system security controls, if you do not continue
to the next section within a 30 minute time period. You will need to successfully (without any
errors) click the SAVE & CONTINUE button in order to continue to the next section of the online form.

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SECTION B: ELIGIBILITY
You do not meet the eligibility requirements for the National Health Service Corps Scholarship program.
Therefore, you will not be allowed to continue with the electronic application.
Click here to log out

Click here to review the questions

You will be automatically logged off the session due to system security controls, if you do not continue
to the next section within a 30 minute time period.

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SECTION C: GENERAL INFORMATION
All fields marked with * are required.
1.

* Professional Health Discipline
Discipline:

Specialty:
(See Applicant Information Bulletin)

Your Full Name:
* Last Name:
* First Name:
Middle Initial:
Title:
Suffix:

Address:
* Street Address:

* City:
* State:

Minnesota

* Zip Code:
4.

* E-mail Address:

Social Security
Number: (See Privacy
Act Statement in the
Applicant Information
Bulletin.)

Telephone Numbers
a. Home:

b. * Daytime:
7.

Proof of Citizenship:
(You must answer a, b and c below. If you were born outside of the United States, the Commonwealth of
Puerto Rico, the U.S. Virgin Islands, the Territory of Guam, the Territory of American Samoa or Swains Island,
documentary proof of U.S. citizenship or U.S. national status must be submitted with the application. This may
consist of a copy of your birth certificate that states your U.S. citizenship, the ID page of your U.S. passport,
or a certificate of citizenship or naturalization.)
a. * Are you a citizen or national of the United States?
Yes

b. Place of birth
* City:
State:
Country, if not U.S.A.
c. * Indicate the Month, Day and Year of Birth

8 a.

* Have you ever received Federal support under the Scholarship Program for First-Year Students of
Exceptional Financial Need (EFN)?
(See Applicant Information Bulletin.)
Yes

If yes, please provide documentation from your school with your application.
b.

* Has your school certified you as having a disadvantaged background?
(See Applicant Information Bulletin.)
Yes

If yes, please provide documentation from your school with your application.
9.

Emergency Contact Information: Enter Name, Permanent Address and Telephone Number of the
person through whom you can always be contacted. (e.g. parents, relatives, etc.)
* Last Name:
* First Name:
Middle Initial:
* Street Address:

* City:
* State:

* Zip Code:
* Phone Number:

(If this information changes, it is the responsibility of the applicant to notify the
NHSC Promptly. Failure to contact an applicant of selection for a scholarship due
to a non-notification of changes to the above information may result in deselection.)

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SECTION D: DEGREE INFORMATION
Your answers to this section should pertain only to the degree or certificate program for which you are applying for
a NHSC Scholarship.
All fields marked with * are required.
1.

* What degree or certification will you receive upon completion of your school/program?

If combined, please specify your degree or certification:

* Select the name of the Health Professions School in which you are enrolled or accepted for
enrollment.

If your school name is not present in this list, please enter the name, city and state below:
School Name:
City:
State:
3.

* Indicate the month and year you first entered or will enter the degree or certificate program for
which funding is requested.
(Do not include pre-requisite training.)
Month:

Year:

* Indicate your expected date of graduation from the degree or certification program for which you
are requesting funding.
Month:

Year:

* What is the TOTAL LENGTH, in years, of the degree or certificate program in which you are or will
be enrolled?
Years

* In what year of your degree or certificate program will you be enrolled during the upcoming
school year?

Year
7.

Your tuition and fees for the upcoming school year will be based on which of the following
categories?

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SECTION E: BACKGROUND
All fields marked with * are required.
1.

Individual and Family Background
(This question is for research purposes only and will not be scored. Completion of these questions is voluntary.)

Indicate your gender.

Indicate your ethnicity.

Hispanic or Latino

Indicate your race.
(Select one or more)

American Indian or Alaskan Native

Black or African American

Native Hawaiian or Other Pacific Islander

White

Male

Female
Not Hispanic or Latino

Asian
2.

Educational Background

Enter the name and location of the institution from which you received or will receive your undergraduate
degree.
Name of the Institution?
City
State

* Degree and year received

* Indicate the area of your
undergraduate college
major

2007

Engineering

If other, please specify your undergraduate major:

How did you learn about the National Health Service Corps Scholarship Program? Select all that
apply. (Completion of this question is voluntary)

If other, please specify:

AH = Other Associate

Work Experience

If you received a degree or certificate in a health-related discipline, as indicated in Question 2 of this Section,
did you work in this discipline for 3 years or more?
Yes

Please identify the discipline

Have you ever been employed or had volunteer experience where the population could not access primary
care services or where health care services could not be obtained within 30 minutes travel time from your
place of employment?
Yes

Have you ever been employed or had volunteer experience where at least 50 percent of the employees,
customers, or clients of your place of employment were of the following racial/ethnic groups: Blacks,
Hispanics, American Indians or Alaskan Natives, Asian/Native Hawaiian or Pacific Islanders?
Yes

5.
a.

Volunteer Experience. Please list your 5 most relevant volunteer experiences.
Experience 1
Activity
Dates Involved

From:

To:

From:

To:

From:

To:

From:

To:

Hours Spent per Event
Frequency

Experience 2
Activity
Dates Involved
Hours Spent per Event
Frequency

Experience 3
Activity
Dates Involved
Hours Spent per Event
Frequency

Experience 4
Activity
Dates Involved
Hours Spent per Event
Frequency

Experience 5
Activity
Dates Involved

From:

To:

Hours Spent per Event
Frequency

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SECTION F: CAREER GOALS
All fields marked with * are required.
1.

Future Plans
*Select the appropriate code for your future Specialty Interest.
Specialty:
If other, please specify:

Instructions: You are required to provide an essay-style response to each of the 5 questions below.
Each response should be limited to 2,500 characters or less (approximately one-half typed page).
To insure that the limit is not exceeded, we recommend that you use a standard word processing
tool (Word, Word perfect, etc.) to create the document and then cut and paste the text into the
online form. Most word processing tools provide you with the character count in addition to
providing spelling and grammar checking.
a.

Why do you want to be a National Health Service Corps Scholar?

When did you realize you wanted to serve underserved populations and how did you arrive at this
decision?

What experiences have you had or activities have you participated in that have prepared you for
working with underserved populations?

If you were selected, how do you envision your service as a provider/employee at a health clinic
in a medically underserved community?

What are your long-term professional plans after fulfilling your scholarship service obligation?

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SECTION G: CERTIFICATION
The check box marked with * is required.
Your Application Form is now ready to Submit. Please complete the certification and then submit your Application
Form. This online Application Form must be Submitted by midnight on March 28, 2008.
We recommend that you review the complete Application Form before you submit it. Click here for a complete,
printable version of the form for your records in Portable Document Format (PDF). You may also save this PDF
document to your computer.
By clicking this checkbox, you agree that you have read and understand the statement below.
* I certify that the information given in this application is accurate and complete to the best of my knowledge
and belief. I understand that it may be investigated and that any willfully false representation is sufficient cause
for rejection of this application, or, if awarded a Scholarship, that I am liable for repayment of all awarded funds
and further, that any false statement herein may be punished as a felony under U.S. code, Title 18, Section
1001.
You must print this form, sign and date it and then submit it with your application documents. Your
application will not be complete if you fail to include this document.
Click Here to print this form

IMPORTANT!
Once you press the "Submit" button, you will not be able to log into the online Application Form to revise
or change your answers. Please be certain your Application Form is complete before proceeding.
If our review shows deficiencies or missing information you will be advised via Email.
If your Application Form is ready, then click on the Submit button below.
Submit

You will be automatically logged off the session due to system security controls, if you do not continue
to the next section within a 30 minute time period.

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SECTION G: CERTIFICATION
Thank you for completing the National Health Service Corps (NHSC) Scholarship Program Application Form. At
this time, you have only fulfilled the first portion of the application requirements. Please see your
Applicant Information Bulletin for further instructions regarding submission of supporting documentation,
including the NHSC Scholarship Program Contract.
Click here for a complete, printable version of the form for your records in Portable Document Format (PDF).
Please save this PDF document to your computer and/or print the PDF document. Please submit a printed copy of
this application form along with your final application package. If you do not have a PDF viewer installed, please
click here to download a free PDF viewer.
Please feel free to contact an NHSC Scholarship Program representative at (800) 638-0824 if you have any
questions or concerns.

Scholarship Program: FAQs | Applicant Information Bulletin

File Type	application/pdf
File Modified	2007-12-21
File Created	2007-12-03