Form 1 NHSC SP – Enrollment Verification Form

BUREAU OF CLINICIAN RECRUITMENT AND SERVICE
5600 FISHERS LANE, RM. 8-37, ROCKVILLE, MD 20857, FAX: 301-451-5557
NATIONAL HEALTH SERVICE CORPS SCHOLARSHIP PROGRAM

SCHOLAR ENROLLMENT VERIFICATION FORM
Spring 2014
Enter the required information below. Include notification from your school confirming any change in your curriculum or date
of graduation. Return a copy of this form, along with a copy of your unofficial transcript to the above fax number. Failure to
submit this form or accurately complete all fields may delay your Tuition and Stipend payments.

Personal Information:
Name: _____________________________________
Mailing Address: _________________________________
City: ____________________ State: _________ ZIP:_________

Last 4 digits of SSN: ______________
Phone (Day): ___________________________
Phone (Evening): _______________________

Email (School): __________________________________

Email (Home): _____________________________________

Emergency Contact:
Name: __________________________________
Phone: ______________________________

Relationship: ____________________________________
Email Address: ____________________________________

Program Information: 
School Name: _____________________________

Discipline:__________________

Specialty:___________________

Address: ____________________________________

School Start Date: __________

Graduation Date: _____________

City: ______________ State: ________ ZIP: __________
Program Length:
Year In School:
__________________
__________________

Final Term?
Yes No

(mm/dd/yyyy)

If Yes, Last Day of Class:
_______________

Indicate your current in‐school status below: 

Full time curriculum (in good standing)

On an approved leave of absence

Part-time curriculum
On academic probation (Explain below)

Repeating coursework

Withdrawn from school (Explain below)

Declining support from: __________ until: __________

Other status (Explain below)

Use this space to explain:

Certification: I certify that the information provided on this Scholar Enrollment Verification Sheet is accurate and complete to the best of my knowledge and
belief. I understand that any willfully false statements made herein may be investigated and may be punishable as a felony under U.S. Code, Title 18,
Section 1001. 

Scholar Signature: ___________________________________
Print Name: ___________________________________
Date:

School Official’s Signature: _____________________________
Title: _________________________________
Print Name: __________________________________________
Date: __________ Phone: ________________________
Email: ___________________________________________

(Official Use Only)
Reviewed and Approved:

EVF

Date

Transcript

NHSC SP Analyst Signature

Print Name