Form 2 School Enrollment Verification Form

DIPL

Name

Nursing Program
Completion Date

DNP

Term/Semester Dates
(mm/dd/yy - mm/dd/yy)

State:

YEAR:

Graduation Date

7 = Other Status (plese explain)

6= Not Enrolled (Summer Only)

5= Withdrawn/ Dropped out of School

4= Leave of Absence
*raised seal - shade with
pencil or crayon

School Seal/Stamp

TITLE:
E-MAIL ADDRESS:
FAX NUMBER:

PRINT NAME:

PHONE NUMBER:

ADDRESS:

PUBLIC BURDEN STATEMENT:

DATE:

School Representative
SIGNATURE:

By signing my name below, I certify that the current status of the student listed above has been correctly identified from the categories provided above.

Explain/Comments:

3 = Repeating Course Work

2 = Part-Time Enrollment in Nursing Program

CATEGORIES: (if applicable check more than 1 category)
1 = Full-Time Enrollment in Nursing Program

FORM APPROVED
OMB No. 0915-0301
Expires 05/31/20

Specialty for NPs and Direct Entry Masters NPs:

Program Year

2020

Please indicate below the current student status, which of the following categories apply. If applicable, list a new graduation date in the comments column.

Program:

Degree

Enrolled

SSN (Last 4 digits)

School Name:

*THIS FORM IS TO BE COMPLETED BY A SCHOOL OFFICIAL

School Enrollment Verification Form TERM:

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