NHSC_SP_002 Acceptance & Declination Form

Application for Participation in the National Health Service Corps Scholarship Program

NHSC Applicant acceptance or denial letter-revised

Application for Participation in the National Health Service Corps Scholarship Program

OMB: 0915-0146

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O.M.B.: 0915-0146 Expiration February 28, 2014



Dear National Health Service Corps Scholarship Program Applicant:



Thank you for your interest in the National Health Service Corps (NHSC).


This letter is to inform you that your Fiscal Year 2011 application has been reviewed and you have been deemed eligible for an NHSC award.


Obtaining responses to this e-mail is the next step in determining who will receive NSP awards.  The Bureau of Clinician Recruitment and Service, Health Resources and Services Administration will determine scholarship recipients by July 30, 2011.


This e-mail is being sent to applicants who are considered finalists and alternates.  Therefore, this is not a guarantee that you will receive an award. 


Please indicate below, if you would accept or decline the NHSC award offer. Please print this e-mail, check the appropriate line below, sign your name, and enter the date and the last four digits of your social security number.


After completing the acceptance form, please fax this document before July 30, 2010 to:


            National Health Service Corps Scholarship Progam

            Fax Number (301) 451-5629


NATIONAL HEALTH SERVICE CORPS SCHOLARSHIP PROGRAM VERIFICATION OF ACCEPTANCE OR DECLINE OF AWARD


____   I will accept the Fiscal Year 2011 NHSC award if it is offered to me.


____   I will decline the Fiscal Year 2011 NHSC award if it is offered to me.



____________________________________           _______________________

Applicant Signature                                                                        Date


____________________________________           _______________________

Applicant First and Last Name (PLEASE PRINT) Last 4 Digits of SSN


If you have any questions, please contact your state analyst identified in the email.


Sincerely,


The National Health Service Corps Scholarship Program

File Typeapplication/msword
File TitleDear Nursing Scholarship Program Applicant:
AuthorHrsa
Last Modified ByJWashington
File Modified2010-12-17
File Created2010-12-17

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