Form 1 NHSC SP Enrollment Verification Form

FALL 2017
Scholar Enrollment Verification Form (EVF)
To receive an NHSC award, you must be enrolled full time and be in good academic standing by
September 30, 2017. This document must be fully completed and signed by you and your school official.
Current year school term system:

Semester

Did you complete summer courses in 2017 for the degree program that you are currently enrolled?

Yes

No

PERSONAL INFORMATION
Name: ________________________________________________

Phone (Day) : ___________________________
Phone (Evening): ________________________

Mailing Address:________________________________________
Email (Primary): _________________________
City: __________________________State: ______Zip:_________

Email (Secondary):________________________

PROGRAM INFORMATION
Program Start date:
School Name: ___________________________

Program Length: _____________ Year in Program: _________

MM

Tentative Graduation date:

Last date of class:

Specialty: ____________________________________________

Is this your final term:

DD

 On academic probation (explain below)

YYYY

YYYY

___/___/_____
MM

SELECT YOUR CURRENT IN-SCHOOL STATUS BELOW (check all that apply):
 Full Time (in good academic standing)
 Part Time

DD

___/___/____
MM

Discipline: ___________________________________________

 On an approved leave of absence

___/___/____

State:______

DD

 Yes

YYYY

 No

 Repeating coursework

 Other status (must explain below)

Explain:

I certify that the information provided on EVF is accurate and complete to the best of my knowledge and belief. I understand that
any willfully false statements made herein may be investigated and may be punishable as a felony under U.S. Code, Title 18,
Section 1001.

____________________________________________

__________________________________________

Scholar’s Signature

School Official’s Name

Date

________________________________________________
School Official Signature
Date

Phone: ________________________________________
Email: _________________________________________