Attachment F - Employment Certification Form

Form Approved
OMB No. 0915-0301
Expires 07/31/2009

Nursing Scholarship Program
Employment Certification Form
PART I: TO BE COMPLETED BY SCHOLARSHIP RECIPIENT
Name: _____________________________________________
Address: ___________________________________________
City, state, zip: _______________________________________
Phone: _____________________________________________
Email address: _______________________________________
Place of Employment: _________________________________
Employment Address: _________________________________
City, state, Zip: ________________________________________
Your position/title: _____________________________________
Date of employment as a Registered Nurse began in this job on:
___________________
Hours per week of clinical practice: ________________________
Type of health care facility (check one):
___ Hospital
___ Indian Health Service Health Center
___ Native Hawaiian Health Center
___ Federally Qualified Health Center
___ Rural Health Clinic
___ Nursing Home
___ Home Health Agency
___ Hospice Program
___ State or Local Public Health Department
___ Skilled Nursing Facility
___ Ambulatory Surgical Center
I certify that I am employed as a Registered Nurse in the facility identified
above and all the information is correct to the best of my knowledge. If I
have a change in employment status, I will notify the Nursing Scholarship
Program within 30 days.
Signature: ___________________________

Date: ___________

CONTINUE ON OTHER SIDE

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PART II: TO BE COMPLETED BY EMPLOYER
I certify that the information concerning employment of the person listed
as a Registered Nurse is correct.
Name of certifying official: ________________________________
Title: _________________________________________________
Phone number: _________________________________________
Email address: _________________________________________
Has Employee Been Absent (e.g., on vacation, holidays, maternity leave,
sick leave, etc.) for more than 7 weeks (28 work days) this year?
YES _____ NO _____ (If yes, please explain)

Signature: _____________________________ Date: ___________
After the form is completed, please mail to:
Nursing Scholarship Program
Division of Scholar and Clinician Support, BCRS
5600 Fishers Lane, Room 8A-19
Rockville, MD 20857
Fax: 301-451-5384

══════════════════════════════════════════════════
FOR NURSING SCHOLARSHIP PROGRAM OFFICE USE ONLY:
Health Care Facility Verification
___ Approved
___ Disapproved
Name of Program Official: __________________________________
Title: __________________________________________________
Signature: _____________________________ Date: ___________