SMART Scholarship Participant Information Verification

SMART Scholarship-for-Service Program

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OMB No.
OMB approval expires

Participant Information Verification
PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 2192a, Science, Mathematics, and Research for Transformation (SMART) Defense Education Program; 5 U.S.C. 3304, Competitive service
examinations; 20 U.S.C. 17, National Defense Education Program; and E.O. 9397 (SSN), as amended.
PRINCIPLE PURPOSE(S): To record contact information for SMART participants.
ROUTINE USES: Disclosure of records are generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended. To academic institutions for the
purpose of providing progress reports for applicants and participants; to consumer reporting agencies as defined in the Fair Credit Reporting Act (15 U.S.C.
1681a(f)) or the Federal Claims Collection Act of 1966 (31 U.S.C. 3701(a)(3)). The purpose of this disclosure is to aid in the collection of outstanding debts owed to the
Federal government, typically to provide an incentive for debtors to repay delinquent Federal government debts by making these debts part of their credit records;
Applicable Blanket Routine Use(s) are: Law Enforcement Routine Use, Congressional Inquiries Disclosure Routine Use, Disclosure When Requesting Information
Routine Use, Disclosure of Requested Information Routine Use, Disclosure to the Department of Justice for Litigation Routine Use, Disclosure of Information to the
National Archives and Records Administration Routine Use, and Data Breach Remediation Purposes Routine Use.
The DoD Blanket Routine Uses set forth at the beginning of the Office of the Secretary of Defense (OSD) compilation of systems of records notices
may apply to this system. The complete list of DoD Blanket Routine Uses can be found Online at:
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx
The applicable Privacy Act System of Records Notice is DUSDA 14, Science, Mathematics, and Research for Transformation (SMART) Information Management
System, found at http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570592/dusda-14.aspx
DISCLOSURE: Voluntary; however, failure to provide the requested information could result in SMART participant not being compliant with SMART policy and subject
to possible dismissal.

SECTION 1 – Contact Information Verification
LAST:
First:
Middle:

Preferred Name (nickname):

Primary Phone Number:

Home

Cell

Work

Secondary Phone Number:

Home

Cell

Work

Alternate Phone Number:

Home

Cell

Work

Primary Email:

Personal

Work

Secondary Email:

Personal

Work

Academic State:

State in which academic institution attended by participant is located.

Sponsoring Facility/Internship State:

State in which participant will be completing SMART internship/sponsoring facility state.

Residence State:

State in which participant claims permanent legal residency.

Primary Address:
Street Number and Name
Apartment Number
City
State and Zip Code
Secondary Address:
Street Number and Name
Apartment Number
City
State and Zip Code

Permanent

School/Temporary

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Permanent

School/Temporary

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

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SMART Participant Information Verification, revised 2015

SMART Scholarship-for-Service Program

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SECTION 2 – SMART Scholarship Program Participant Contact List
___ Yes, I would like to participant in the SMART Scholarship Program Participant (SSPP) Information Share. I allow my name and
contact information to be accessable to all SSPPs via the SMART Portal for a period of one year.
___ No, I would not like to participant in the SMART Scholarship Program Participant (SSPP) Information Share via the SMART
Portal. Please do not distribute my name and contact information.
a. NAME (Last, First, Middle Initial)
b. SIGNATURE
c. DATE SIGNED (MMDDYYYY)

SECTION 3 – General Questions/Comments for Cohort Administrator

Agency Disclosure Notice
The public reporting burden for this collection of information is estimated to average 30 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, Directives Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 OMB Control
Number: 0704-0466. Respondents should be aware that notwithstanding any other provisions 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.

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SMART Participant Information Verification, revised 2015