E Attachment E - Confirmation of Interest Form Screenshots

NURSE Corps Scholarship Program Application

NURSE Corps Scholarship Program Application
Congratulations! Your application has been identified as a possible
recipient for a 2017 NURSE Corps
Scholarship Program
award. This is not a guarantee of an award. At
this time, it is required you complete the following steps by  9/6/2017
.
Please also make sure that your contact information is up to date in
your Account Settings
.
Your overall Application Status is: Finalist for
Award
View your submitted application

Step 1

Please confirm or decline your intent to accept the NURSE Corps Scholarship Program award below:
I wish to be considered for the 2017 NURSE Corps Scholarship Program Award.
I am no longer interested in receiving the 2017 NURSE Corps Scholarship Program Award. I
understand that I will no longer be considered for a NURSE Corps Scholarship Program award.

Step 2

Please enter your banking information. This is
used to deposit your scholarship funds as a participant
of the
NURSE Corps Scholarship Program. This should be the account you
wish the NURSE Corps
Scholarship Program to deposit funds in.
Bank Name *
Select
Select

Account Type *

Checking

Routing Number *

Re-enter Routing Number *
Account Number *

Re-enter Account Number *

Step 3

Please upload your
W-4 below:*
no file selected

Step 4

Please upload your Fall Enrollment Verification Form below:*
no file selected

Step 5

Please upload your Summer Enrollment Verification Form below:
no file selected

Step 6

State whether you'd like to receive your tax documents
electronically and be available from the Portal or if
you'd
like to receive them by mail.

http://hrsabmissdev3.nih.gov:9000/extranet/application/ncsp/private/landing.seam?cid=95[9/5/2017 2:23:06 PM]

NURSE Corps Scholarship Program Application

AGREEMENT
As a scholarship or loan repayment program participant, you have the option to receive your tax
documents (Form W-2, and if applicable, Form 1099-Misc.) in an electronic format. If you do not
consent to receive your tax documents electronically you will continue to receive paper copies via
mail. If you consent to receive your tax documents electronically you will receive your electronic
documents for the applicable tax year immediately following the date of your consent and all future
years, unless you withdraw your consent.
You may receive paper tax documents or electronic tax documents but not both. Tax documents
will be furnished based on your delivery preference in effect as of January 16th each year. You are
not required to update your preference yearly. However, you will be able to change your preference
using the "Set My Tax Document Delivery Preference"link in the "I Need to" section of the BHW
Program Portal until 11:59 PM EST January 15th of each year.
If you previously set your preference to receive electronic tax documents but subsequently change
your preference to receive paper copies, your withdrawal of consent will apply only to future tax
documents that have not already been provided electronically.

Please select your tax document delivery preference *
Yes, I have read the above Disclosure Statement and consent to receive my tax documentation
electronically via my BHW portal account.
No, I do not wish to receive tax documents electronically. I wish to receive documents via mail.

Continue

http://hrsabmissdev3.nih.gov:9000/extranet/application/ncsp/private/landing.seam?cid=95[9/5/2017 2:23:06 PM]

Sign Your Electronic Contract - NURSE Corps Scholarship Program Application

Sign your Electronic Contract
* required field
Back
This contract is not binding until countersigned by the Secretary of the Department of Health and Human Services or his/her
designee.
View a printable version of the NURSE Corps Scholarship Program contract

CONTRACT

Please review this table to understand the number of years required for service if
awarded.
Years of Scholarship Support

Years of Service Obligation

Up to 1 Full-Time School Years (2017-2018)

2 Years Full-Time

Up to 2 Full-Time School Years (2017-2019)

2 Years Full-Time

Up to 3 Full-Time School Years (2017-2020)

3 Years Full-Time

Up to 4 Full-Time School Years (2017-2021)

4 Years Full-Time

CERTIFICATION
Years of funding requested *

22
3

By certifying this document, I verify the following: *
My program starts on or before September
30, 2017.
I agree to
2 years of service obligation
for 2 year(s) of scholarship
support
I understand that if I request a change
to the funding years I initially applied for, this change may
impact the
number of years I am obligated to serve at an NHSC
approved site.
I understand the minimum service
obligation is 2 years, even if I request just one year of
NHSC Support.

Yes

No

ENTER SIGNATURE INFORMATION
SSN *

Confirm SSN *

http://hrsabmissdev3.nih.gov:9000/extranet/application/ncsp/private/coi-accept.seam?cid=95[9/5/2017 2:26:09 PM]

Sign Your Electronic Contract - NURSE Corps Scholarship Program Application

What is the street number of the house you grew up
in? *

Password *

Sign and Submit

http://hrsabmissdev3.nih.gov:9000/extranet/application/ncsp/private/coi-accept.seam?cid=95[9/5/2017 2:26:09 PM]

NURSE Corps Scholarship Program Application

NURSE Corps Scholarship Program Application
Hello Jenna,
You have confirmed your intent to accept the 2017
NURSE Corps Scholarship Program award. You are not guaranteed an award
at this time. We will review the information you submitted as part of your
acceptance to ensure completeness and accuracy.
Please wait for the NURSE Corps Scholarship Program to contact you regarding your award.
The NURSE Corps SP uses your primary email address to communicate application status changes and requests for more
information regarding your application. Please ensure that we always have the most accurate contact information.
All awards will be made by September 30th 2017.
Your overall application status is: In Final Review
Your application ID is: 387706
View your submitted application
Your NURSE Corps Scholarship Program signed contract

GENERAL SUPPORTING DOCUMENTS
Document Title

Document Name

Status

Authorization to Release Information

EPSON020.PDF

Received

Complete Official Student Aid Report

2017 Complete Student Aid Report.pdf

Received

Current Year Tuition and Fees Schedule

2017 Tuition and Fees.pdf

Received

Essay 1 - Mission of NURSE Corps SP

2017 Essay 1.pdf

Received

Essay 2 - Experience in Underserved Communities

2017 Essay 2.pdf

Received

Essay 3 - Service Commitment

2017 Essay 3.pdf

Received

Proof of Citizenship or U.S. National; Lawful Permanent Resident

Proof of Citizenship.pdf

Received

Resume/CV

2017 Resume.pdf

Received

Transcript

2017 Transcript.pdf

Received

Verification of Acceptance/Good Standing

EPSON021.PDF

Received

CONFIRMATION OF INTEREST SUPPORTING DOCUMENTS
Document Title

Document Name

Status

W-4 Form

TEST DOCUMENT PDF.pdf

Received

Education Verification Form - Fall

TEST DOCUMENT PDF.pdf

Received

Education Verification Form - Summer

TEST DOCUMENT PDF.pdf

Received

http://hrsabmissdev3.nih.gov:9000/extranet/application/ncsp/private/landing.seam?cid=95[9/5/2017 2:26:38 PM]

NURSE Corps Scholarship Program Application

NURSE Corps Scholarship Program Application
Congratulations! Your application has been identified as a possible
recipient for a 2017 NURSE Corps
Scholarship Program
award. This is not a guarantee of an award. At
this time, it is required you complete the following steps by  9/6/2017
.
Please also make sure that your contact information is up to date in
your Account Settings
.
Your overall Application Status is: Finalist for
Award
View your submitted application

Step 1

Please confirm or decline your intent to accept the NURSE Corps Scholarship Program award below:
I wish to be considered for the 2017 NURSE Corps Scholarship Program Award.
I am no longer interested in receiving the 2017 NURSE Corps Scholarship Program Award. I
understand that I will no longer be considered for a NURSE Corps Scholarship Program award.

Continue

http://hrsabmissdev3.nih.gov:9000/extranet/application/ncsp/private/landing.seam?cid=92[9/5/2017 2:20:19 PM]

Decline Offer of the NURSE Corps Scholarship Program Award - NURSE Corps Scholarship Program Application

Decline Offer of the NURSE Corps Scholarship Program
Award
* required field
Back
You have indicated that you are no longer interested in receiving the NURSE Corps Scholarship Program award. If this is not
correct you may go back and change your answer by selecting the Home link at the top of the page.
Please indicate your reason for declining the
NURSE Corps Scholarship Program award. *

Decline

http://hrsabmissdev3.nih.gov:9000/extranet/application/ncsp/private/coi-decline.seam?cid=92[9/5/2017 2:20:33 PM]

NURSE Corps Scholarship Program Application

NURSE Corps Scholarship Program Application
Hello Marilynn,
You have withdrawn your application for the 2017 NURSE Corps Scholarship Program because you have declined your interest in
the award.
Your online application will be removed from consideration and is no longer eligible for an award.
Your overall application status is: Declined Award
Your application ID is: 377795
View your submitted application

GENERAL SUPPORTING DOCUMENTS
Document Title

Document Name

Status

Authorization to Release Information

Nurse Corp Release.pdf

Received

Complete Official Student Aid Report

Nurse Corp FASFA SAR 2017-2018.pdf

Received

Current Year Tuition and Fees Schedule

Nurse Corp Tuition and Fees.pdf

Received

Essay 1 - Mission of NURSE Corps SP

Essay Question 1.docx

Received

Essay 2 - Experience in Underserved Communities

Essay Question 2.docx

Received

Essay 3 - Service Commitment

Essay Question 3.docx

Received

Proof of Citizenship or U.S. National; Lawful Permanent Resident

Mari's Birth Certificate.pdf

Received

Resume/CV

Mari Resume.docx

Received

Transcript

Clemson Transcript.pdf

Received

Verification of Acceptance/Good Standing

Nurse Corp Verification of Acceptance.pdf

Received

http://hrsabmissdev3.nih.gov:9000/extranet/application/ncsp/private/landing.seam?cid=92[9/5/2017 2:20:59 PM]