Loan For Service Employment Verification Form
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DUCATION
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For NMHED Use Only
Year ________ of _________
_______/________/________- _______/________/_______
Program Coordinator Initials________________
Financial Aid Manager Initials________________
Date:________________
Date:_________________
APPROVED
DENIED
APPROVED
DENIED
LOAN FOR SERVICE EMPLOYMENT VERIFICATION FORM
SECTION 1: General Information (to be completed by borrower)
First Name: _______________________ Last Name:____________________________ MI:______
Previous Name under which records may be kept:________________________________________
Loan-for-Service Program Name:______________________________________________________
Last four digits of SS#:____________________________ Birth Date:________________________
Drivers License Number:___________________________ Exp. Date:________________________
Mailing Address:___________________________________________________________________
City:___________________________________ State:____________________ Zip:____________
Home Phone #:_________________ Work Phone #:________________ Cell Phone #:___________
Primary Email:____________________________________________________________________
*NMHED will send the majority of communication via email. Please ensure your email address is accurate.
Graduation Date:______________________ Degree Completed:____________________________
University/College Name:____________________________________________________________
*Attach a copy of the following:
1. A copy of your driver’s license.
2. A copy of your professional license/certificate.
3. A letter on official letterhead MUST be attached from your employer with verification of
employment profession, start date, and hours worked weekly.
I hereby authorize release of the information requested in Section 2.
Signature
Date
2048 Galisteo Street, Santa Fe, New Mexico 87505
Toll Free Phone: 1-800-279-9777, Fax: 505-476-8454
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