10-264M Mobility Agreement

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

READJUSTMENT COUNSELING SERVICE SCHOLARSHIP PROGRAM (RCSSP)

MOBILITY AGREEMENT

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.

The purpose of the scholarship program is to award scholarships to students receiving education or training in a direct or indirect health-care 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, RCSSP scholarship program participants must agree to serve a minimum 6-year service obligation.
Name of Applicant (Last, First, MI):
SSN (Last 4 Only):

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.

Initial Here

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 RCSSP 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
RCSSP 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
NOV 2021

10-264M

Signature of Program Participant

Date (MM/DD/YYYY)

E-mail Address

10RCS

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