10-264H Notice of Approaching Graduation

OMB Control No. 2900-XXXX
Estimated Burden: 10 Minutes
Expiration Date: XXXXX XX, 20XX

READJUSTMENT COUNSELING SERVICE SCHOLARSHIP PROGRAM (RCSSP)

NOTICE OF APPROACHING GRADUATION

Submit this completed form to the Readjustment Counseling Service Scholarship Program Office 6 months prior to graduation.
RCSSP
Department of Veterans Affairs, Readjustment Counseling Service (10RCS)
810 Vermont Ave., NW, Washington, DC 20420
THE PAPERWORK REDUCTION ACT OF 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995.
Therefore, we may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate
that the time expended by all individuals who complete this form will average 10 minutes. This includes the time it will take to follow instructions, gather the necessary
facts, and fill out the form.
PRIVACY ACT NOTICE: The VA is asking you to provide the information on this form under the authority of 38 CFR, sections 17.545 through 17.553 (RCSSP) 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.
RCSSP
Student's Name (Last, First, Middle):

Social Security Number:

Clinical Program (Check one only):
Psychology

Social Work

Email Address:
Type of Degree (Check one only):

MHPC

Expected Date Requirements will be met
(MM/DD/YYYY):

MNFT

Master's Degree

Doctoral Degree

I verify the student's expected graduation information is accurate to the best of my knowledge.

Scheduled Graduation Date (MM/DD/YYYY):
Academic Advisor's Signature
Please check applicable boxes:
I intend to begin my service obligation no later than 180 days after the educational and/or certification qualifications are met and I have been
accepted for an employment position. I do not intend to request a deferement of my service obligation.
I have submitted applications for employment at VA facilities for my service obligation.

(Please send a copy of your Optional Application for Federal Employment (OF 612) or a copy of the position application)
I have been selected by a VA facility for my service obligation.

(Submit the Status Report on Service Obligation Placement form along with this Notification of Approaching Graduation)
(Please send a copy of your Optional Application for Federal Employment (OF 612) or a copy of the position application)
I have not submitted applications for employment at VA facilities for my service obligation.
I intend to submit my applications for employment no later than
Date (MM/DD/YYYY)
I intend to request a deferment of my service obligation in order to complete advanced clinical education.

(Submit the Request for Deferment form along with this Notification of Impending Graduation)
(Please send a copy of your Optional Application for Federal Employment (OF 612) or a copy of the position application)

Signature
VA FORM
NOV 2021

10-264H

Date (MM/DD/YYYY)

10RCS

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