Form 1 NHSC SP – Receipt of Exceptional Financial Need Scholars

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

RECEIPT OF EXCEPTIONAL FINANCIAL NEED SCHOLARSHIP
(For School Use Only – Must be Completed by Financial Aid Official)

Name of Student: _____________________________________

_________________

Last 4 digits of the Student’s Social Security Number: ________________________________________

The Financial Aid Official identified below certifies that the above-named student
 has received
 has not received
a Scholarship for Students of Exceptional Financial Need (EFN) under former section 758 of the Public
Health Service Act (applicable to medical and dental students only).

SUBMITTED BY:
Signature & Date:
Name:
Title & Phone Number:
E-Mail Address:
Name of School:

Student may upload signed form to the NHSC SP Online Application: https://programportal.hrsa.gov/