VA Form 10-0491k HPSP/VIOMPSP VA Scholarship Offer Response

OMB Number: 2900-0793
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)

VA Scholarship Offer Response
PRIVACY ACT NOTICE
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 your 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 your 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 your request for a scholarship. If you give
VA your social security number, VA will use it to obtain information relevant to determining whether to grant a scholarship, and to administer your scholarship, if awarded.
It also may be used for other purposes authorized or required by law.

Applicant's (Last, First, MI):

Social Security Number:

Please indicate whether you are
accepting or declining the Department
of Veterans Affairs scholarship award
by checking the appropriate space
below.
The scholarship award will not be issued
until this form is completed and received
by the scholarship program office.

Health Professional Scholarship Program (HPSP) or Veterans Healing Veterans Medical Access
and Education Scholarship Program (VHVMAESP)
I accept the scholarship award for the 20 __ - 20 __ school year.
I decline the scholarship award for the 20 __ - 20 __ school year.
Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
I accept the scholarship award for the 20 __ - 20 __ school year.
I decline the scholarship award for the 20 __ - 20 __ school year.

A. I understand that the VA will require me to maintain enrollment, an acceptable level of academic standing, and complete all
coursework in the course of study for which the scholarship award is provided.

Initial

B. I understand that the VA will require me to notify the scholarship program in writing, within 10 days if I change my enrollment
status, plan of study, academic standing, name, mailing address, telephone number, e-mail address, or bank information.

Initial

C. FOR HPSP/VHVMAESP ONLY. I understand that I will make every effort to attend a required clinical tour in an assignment
or location determined by VA while enrolled in the course of education for which the scholarship is provided. For VHVMAESP
recipients, this includes two funded rotations during the fourth year of medical school at a VHA facility as determined by VA.

Initial

D. I understand the required service obligation to work in a VA health care facility in a full-time position for which I will be prepared
after completing the education program supported by the scholarship program.

Initial

E. I understand that the VA agrees to provide an appointment to a full-time position providing health services in the profession for
which the scholarship is provided.

Initial

F. I understand that I may be subject to the penalties as described in the scholarship agreement if I do not complete the education
Initial
program for which I am requesting scholarship support or if I do not complete the required service obligation.
I accept this scholarship award with the terms and conditions that have been explained to me, and which are included in this document.
Applicant's Signature

Date

My address, e-mail, and phone number are the same as on my application.

Please update my contact information as indicated below.

New Address (Include Street Address, City, State, and ZIP Code):
New E-mail:

New Phone Number:

Payment Information for the direct deposit of stipends and reimbursement of other related costs. Direct deposit of funds is required.
Name of Financial Institution:

Please indicate Account Type:

Account Number:

Checking

Routing Number:

Savings

If you have any questions please contact the Department of Veterans Affairs, Scholarships and Clinical Education Program Office
[email protected]
Complete this form and return immediately to:
HPSP/VIOMPSP/VHVMAESP Department of Veterans Affairs, 1250 Poydras St., Suite 1000, New Orleans, LA 70113
Retain this attachment until you are notified of your selection as a scholarship recipient. Do not mail this form with your application.
VA FORM
DEC 2018

10-0491K

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