Form Nih 2762-3 - Undergraduate Scholarship Program (Ugsp) - Academic Enrollment Certification And Service Obligation Deferment Request - U.s. Department Of Health And Human Services

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Last Updated – August 20, 2015

OMB No. 0925-0299

Form approved for use through 08/31/2016

U.S. Department of Health and Human Services

National Institutes of Health

Undergraduate Scholarship Program (UGSP) – Academic Enrollment Certification and Service Obligation Deferment Request

Applicant’s Instructions – Please complete

Academic Institution’s Instructions – Please complete Section B and return the form by mail to

Section A. Give this form to the Registrar’s

National Institutes of Health Undergraduate Scholarship Program, 2 Center Drive / Room 2E26

Office at the school at which you are enrolled

(MSC 0230), Bethesda, Maryland 20892-0230. Or fax to 301-594-9606. If you have any questions,

starting September 2015.

call 301-443-8215 or e-mail Dr. Rayna Truelove at rayna.truelove@nih.gov

Section A – The applicant completes this section.

1. Applicant’s Name (last, first, middle)

1a. Other Names Used on Official Documents (last, first, middle)

2. Student Identification Number

3. NIH Badge Number (completed by UGSP office)

Check One:

! I am enrolled full-time in an accredited Undergraduate Program. University Name__________________________________________________

! I meet the qualifications for the deferment checked below and request that the NIH Undergraduate Scholarship Program defer my service

obligation for the academic period from _________________________ to _________________________.

! While I am enrolled full-time in an accredited MEDICAL SCHOOL.

! While I am enrolled full-time in an approved GRADUATE PROGRAM.

I authorize the institution indicated in Section B to release information about my academic enrollment to administrators of the NIH Undergraduate

Scholarship Program (UGSP) and to other authorized Government officials.

Signature (Sign your full name in ink)______________________________________________________________ Date______________________

Section B – To be completed by Academic Institution Registrar’s Office

I certify, to the best of my knowledge, that the student named above is/was engaged in the program indicated above, and that the student’s program

meets all the eligibility requirements on this form.

Items (1) and (2) of this section must be completed. The school may attach its own enrollment certification report listing the required information in

lieu of completing this section.

Certification of Academic Institution Registrar’s Office

The student:

(1) Is/was enrolled full-time during the academic period (MM-DD-YYYY)_______________ to (MM-DD-YYYY)_______________.

(2) Is reasonably expected to complete his/her program requirements on (MM-DD-YYYY)_______________.

The undersigned institutional representative certifies that, to the best of his/her knowledge, the information reported above is accurate. This

Certification should include the school’s seal or official stamp.

Name of School ________________________________________________________________________________________________________

Financial Aid Administrator’s Name (please print)_______________________________________Title____________________________________

Signature______________________________________________________________________________Date____________________________

Telephone____________________Fax Number____________________Email Address_______________________________________________

Public reporting burden for this collection of information is estimated to average 15-minutes per response, including the time for reviewing instructions. An agency may not conduct or

sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or

any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD

20892-7974, ATTN: PRA (0925-0299). Do not return the completed form to this address.

NIH 2762-3