VA Form 10-0491m HPSP Mobility Agreement

OMB Number: XXXX-XXXX
Estimated Burden: 10 minutes
Health Professional Scholarship Program (HPSP), Visual Impairment and Orientation and Mobility
Professionals Scholarship Program (VIOMPSP), & Veterans Healing Veterans Medical Access and
Education Scholarship Program (VHVMAESP)

Mobility Agreement

PRIVACY ACT NOTICE
The The VA is asking you to provide the information on this form under the authority of 38 U.S.C. §7501 (VIOMPSP), §7611 (HPSP), and §7601
(VHVMAESP) in order for VA to determine the applicant's eligibility to receive a scholarship award. VA may disclose the information that you put on
the form as permitted by law. VA may make a "routine use" disclosure of the information for: civil or criminal law enforcement; congressional
communications; the collection of money owed to the United States; litigation in which the United States is a party or has interest; the administration of
VA training and scholarship programs, including verification of the applicant's eligibility to participate; and personnel administration. You do not have
to provide this information to VA but, if you do not, VA may be unable to process the applicant's request for a scholarship. If you give VA a social
security number, VA will use it to obtain information relevant to determining whether to grant a scholarship, and to administer the applicant's
scholarship, if awarded. It also may be used for other purposes authorized or required by law.

The purpose of the scholarship program is to award scholarships to students receiving education or training in a direct or indirect healthcare services discipline, and to assist in providing an adequate supply of such personnel for the Department of Veterans Affairs (VA) and
the United States. In exchange for the award, HPSP scholarship program participants must agree to serve a minimum 2-year service
obligation, VIOMPSP scholarship program participants must agree to serve a minimum 3-year service obligation, and VHVMAESP
participants must agree to serve a minimum 4-year service obligation in a VA health care facility as a full-time employee for full-time
students. As a HPSP part-time program participant, the minimum service obligation is 1-year in position for which the degree program
prepared him or her.
SSN (Last 4 Only):

Name of Applicant (Last, First, MI):

Initial Here

Initial Here

I understand that while my preferences will be considered to the extent possible, my initial
assignment after graduation and completion of my licensure/certification, will be made based on
the needs of the Veterans Health Administration and I may be required to accept assignment at
any VHA facility where my services are needed.
I agree to relocate, if necessary, at my own expense to complete my service obligation period in
accordance with Sections C.13 and C.14 of my HPSP Agreement, Section C.11 and C.12 of my
VHVMAESP Agreement, or Sections C.10 and C.11 of my VIOMPSP Agreement.

Initial Here

I understand if my initial assignment is not offered at my facility of choice, relocation benefits
will not be paid by the Scholarships and Clinical Education Office.

Initial Here

I understand, if I refuse to relocate for my initial assignment I am subject to the provisions of
Section D.3 of my HPSP Agreement, VHVMAESP Agreement or VIOMPSP Agreement.

Certification of Accuracy
I acknowledge that by accepting this scholarship, I hereby agree to abide by the terms of this Mobility Agreement.
(Inaccurate data may cause both the school and the student to lose funding.)

Name (Print)

Phone Number (include area code)
VA FORM
Dec 2019

10-0491M

Signature of Program Participant

Date

E-mail Address
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