Application to Participate in Federal Student Financial Aid: Private Sector

OMB No. 1845-0012
Form Approved
Exp. Date: 11/30/2022

Section A.
1.

Please answer these general questions.

Section A

Tell us why you are submitting this application. (You may check more than one box.)

financial aid programs and to be initially designated as an eligible institution for other Higher
Education Amendments (HEA) programs.

student financial aid programs and to be designated as an eligible institution for other HEA
programs following a change in institutional ownership or structure.

either in response to a recertification notice from us or because your institution’s Program
Participation Agreement (PPA) will expire soon.
Designation as an eligible institution. This is a request to be designated as an eligible
institution so that your students may receive deferments under federal student loan programs, so
that your institution may apply to participate in federal HEA programs, including the Title IV
student financial aid programs, or so that your students may claim an education tax credit such as
the American Opportunity Tax Credit or Lifetime Learning Credit.
Reinstatement. This is a request to be reinstated to participate in federal student financial aid
programs and/or to be redesignated as an eligible institution for other HEA programs.

Other (specify)

2.

What is the name of your institution?

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Section A
3a.

Do you have another name such as a trade name or a d/b/a name, under which you legally do
business as a postsecondary educational institution?
Yes

3b.

No

During the last 4 years, have you had another name that you have not previously reported
to the Department of Education?
Yes

4.

Check here if you are an institution resulting from a merger in the past four years
that you have not previously reported to the Department of Education, and give the
names, TIN Numbers, and OPE ID numbers of the former (pre-merger) institutions.
(You must enter the merger date in Question 19 (Section C)).
OPE ID

5.

No

Name

TIN

What is your 8 digit OPE ID Number? (Enter the first 6 digits. The final 2 digits are entered for you.)
Check here if you are an initial applicant and do not have an OPE ID number, and go to
Question 6.
Current OPE ID (or former OPE ID if seeking reinstatement)

00
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Section A
6a.

What is your 9-digit Tax Identification Number (TIN) assigned by the IRS?

6b.

What is your 9-digit DUNS number?

7.

8.

9.

What was your most recently completed award year?
Beginning date:

07/01/

Ending date:

06/30/

What is your current award year?
Beginning date:

07/ 01/

Ending date:

06/30/

(Optional) Does your institution have a website (or home page) on the Internet?
Yes

No

If yes, list the electronic address (URL).

10.

Who is your chief executive officer (CEO)/president/chancellor?
First name, MI, Last name, Suffix

(include prefix, such as Mr., Ms., Dr.)

Job Title

Business street address

City

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Section A

State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)

Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address

11.

Who is your chief fiscal officer/financial officer?
First name, MI, Last name, Suffix
(include prefix, such as Mr., Ms., Dr.)

Job Title

Business street address

City

State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)

Telephone number (including area code)
ext:
Fax number (including area code)
ext:

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