Employment Certification Form printable pdf download

NURSE FACULTY LOAN PROGRAM

EMPLOYMENT CERTIFICATION FORM

[Applicant’s Name] ___________________________________entered into a contractual agreement with the Duke University School of Nursing as

a participant in the Nurse Faculty Loan Program (NFLP). This program requires the participant to be employed full-time as nurse faculty in a school

of nursing for a complete year in order to receive cancellation of his/her loan. Please complete the Employment Certification Form at the bottom and

return to the following:

Mail to:

ECSI, 181 Montour Run Road, Coraopolis, PA 15108

Fax to:

866.291.5384

PART I: TO BE COMPLETED BY LOAN RECIPIENT

Name: _______________________________________________________

Permanent Address: ____________________________________________

Phone Number: _______________

_____________________________________________________________

Place of Employment: __________________________________________

Address: _____________________________________________________

_____________________________________________________________

Beginning Date of Employment as Nurse Faculty:

Month______ Day______ Year_________

Position Title: ______________________________________

I CERTIFY that I am employed full-time as Nurse Faculty in the above named school of nursing, and all the information is true and

correct to the best of my knowledge. If I change employment status, I will notify [Name of Lending School] immediately.

Keep a

copy for your records.

Signature: __________________________________________ Date: ___________________

PART II: TO BE COMPLETED BY EMPLOYER

I CERTIFY that the statements above concerning service of the above named NFLP loan recipient as a full-time nurse faculty are true

and correct.

Keep a copy for your records.

Name of Certifying Official: _____________________________________________________________

Title: ______________________________ Phone Number: _________________ Fax Number: _______________

Signature: ___________________________________________

Date: ___________________

If the above named participant has not maintained faculty status during this period, please provide the date(s) and explanation

for the change.

Date(s): _________________________

Explanation: __________________________________________________________________________________

WARNING: ANY PERSON WHO KNOWLINGLY MAKES A FALSE STATEMENT OR MISREPRESENTATION OF THIS FORM IS

SUBJECT TO PENAL TIES WHICH MAY INCLUDE FINES AND IMPRISONMENT UNDER FEDERAL STATUTE.

Employment Certification Form