Form NHSC_SP_005 Deferment Request Form

DEFERMENT REQUEST FORM FOR 07/01/11-06/30/12

Please fax to the attention of: Division of National Health Service Corps (DNHSC) Fax: (301) 451-5612
Or
Complete the form on the NHSC Self-Service Portal at: https://healthcareheroes.hrsa.gov/extranet/participant/

This document represents a formal request for the deferment of your service obligation incurred under Section 338A of the Public Health Service Act to pursue postgraduate training.

CONDITIONS OF APPROVAL:
- Pursue only the training approved for your deferment.
- Submit documentation of your training status in an approved program prior to each year of training.
- Make no changes in the period or type of training without prior written approval from the DNHSC.
- Notify the DNHSC in writing within 30 days of any change of address, intent to terminate training, or similar change.
Scholar Name: Last 4 Digits SSN: XXX-XX-­
Home Address: Home/Cell Phone Number:
City: State: Zip: E-mail Address:

P ostgraduate (Residency) Training Program Contact Information

Program Director Name: Phone Number:

N ame of Program: Length of Program:
Residency Program ID Number: Date Available for NHSC Service:


Contact Information for the Clinic
Name of Clinic: Phone Number:
Clinic Address: E-mail Address:
City: State: Zip:

Emergency Contact Information
Name: Phone Number:
Home Address: E-mail Address:
City: State: Zip:

I certify that the information given in this request is accurate and complete to the best of my knowledge and belief. I understand that any knowingly and willfully false representation of a material fact may be punishable by fine or imprisonment under U.S. Code Title 18, Section 1001.

Scholar’s Signature: 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 .25 hours per response, including 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.