Form 1 NHSC SP – Acceptance/Verification of Good Standing Repor

National Health Service Corps
Scholarship Program
U.S. Department of Health and Human Services
Health Resources and Services Administration

NATIONAL HEALTH SERVICE CORPS SCHOLARSHIP PROGRAM
ACCEPTANCE REPORT/VERIFICATION OF GOOD STANDING
This Acceptance Report/Verification of Good Standing certifies that the student identified below has been accepted for admission or is enrolled in good standing
for the 2014-2015 school year (i.e., July 1, 2014 – June 30, 2015) as indicated. Please note all information will be verified for accuracy. (To be completed by a
school official only)

1. Student’s Name (Last, First, Middle):

2. Student’s SSN (Last 4 digits):

3. What program is the student admitted to? (Please specify if the program is a dual degree or bridge program.)
4. Is the student in good standing? (If NO, please explain.)

5. Degree/certificate the student will receive upon completion of the program:
6. Student classification as of the 2014-2015 school year:

1st

2

nd

 3

4

rd

th

7. If the student is newly enrolled, is there a contingency to the student’s acceptance to the program other than standard
contingencies that apply to all admitted applicants? Examples include the student needing to repeat a course or the student
receiving an “Incomplete” status for a course.
Yes
No
If YES, please explain:
(All contingencies must be met by June 30, 2014)
8. Student Status (check all that is applicable):

Full-Time Enrollment
Leave of Absence

Part-Time Enrollment
Withdrawn

 Repeating Course Work
 Other (Please explain):

 On Academic Probation

9. What schedule does the school year operate on?
Semester system

Quarter system

 Trimester system

 Other (Please explain):

10. Length of the full-time program (months or years):
11. Date student began the program (mm/yyyy):
12. Date class begins for the school year 2014-2015 (mm/yyyy):
13. Anticipated date of graduation (mm/yyyy):
By signing my name below, I certify that the current status of the student listed above has been correctly identified. I further certify that, where necessary, I have corrected the “Year in
Program” and “Date of Graduation” for the student to accurately reflect the anticipated graduation date given the current enrollment. I understand that any willfully false information may
be punishable as a felony under U.S. Code, Title 18, Section 1001.

SUBMITTED BY:
Signature:
Name:
Phone Number:
Name of School:

Date:
Title:
E-Mail Address:

Student may upload signed form to the NHSC SP Online Application: https://programportal.hrsa.gov/
OMB No. 0915-0146 Expiration 04/30/2014