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

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, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense
Pentagon, Washington, DC 20301-1155 (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 22219
Fax: 703-696-5667
Email: [email protected]

N E E D S

For questions, call or email: (703) 696-1991; [email protected]

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PRIVACY ACT STATEMENT
AUTHORITY: 50 U.S.C. 1901 et seq., as amended; DoD Directive 1025.6, National Security Education Program; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To document recipient's status and compliance in fulfilling the service requirement. The applicable SORN is DHRA 09
located at http://privacy.defense.gov/notices/osd/DHRA09.shtml.
ROUTINE USE(S): In the case of a recipient in default of a service agreement, information may be disclosed to consumer reporting agencies; and to
other governmental agencies to facilitate collection of amounts owed the government. The DoD "Blanket Routine Uses" found at
http://privacy.defense.gov/blanket_uses.shtml also apply.
DISCLOSURE: Voluntary; however, failure to furnish the requested information will result in NSEP not being able to finalize your application for a
scholarship or fellowship. A truncated SSN (last four digits of your Social Security Number) is requested in order to track recipients in the case that
their name and/or address changes.

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

2. FORMER NAME

3. SOCIAL SECURITY NUMBER
(Last 4 digits)

4. CURRENT CONTACT INFORMATION
a. STREET AND APARTMENT/SUITE NUMBER

b. CITY

c. STATE

f. HOME TELEPHONE NUMBER
(Include area code)

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

b. CITY

c. STATE

e. E-MAIL ADDRESS

5. PERMANENT CONTACT INFORMATION
a. STREET AND APARTMENT/SUITE NUMBER

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
degree program at
is (Month/Year)

(Institution); my expected graduation date
. (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 yet 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 extensionas 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.)

DD FORM 2753, 20101208 DRAFT

PREVIOUS EDITION IS OBSOLETE.

Adobe Professional 8.0

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 (YYYYMMDD)

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.

N E E D S

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SECTION IV - CERTIFICATION (NOTE: Service will NOT be approved without supervisor verification and signature.)
a. YES

17. I have activated and updated my resume on NSEPNET.
18. CONTACT INFORMATION FOR EMPLOYING ORGANIZATION
a. NAME OF EMPLOYING ORGANIZATION

c. STREET ADDRESS

b. NO

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

d. CITY

e. STATE

f. ZIP CODE

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 25. APPROVED
APPROVED
MONTHS

DD FORM 2753 (BACK), 20101208 DRAFT

26. MONTHS
REMAINING

27. YEAR OF
AWARD

28. (X)
S

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F

EHLS

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