Form 4735 - Michigan Nursing Scholarship Program Status Report
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2Michigan Department of Treasury
4735 (03/13)
Michigan Nursing Scholarship (MNS) Status Report
As stipulated in the MNS Agreement and Master Promissory Note, scholarship recipients agree to provide written
evidence of compliance with program requirements and to inform the program of any changes in personal information,
educational status, or employment situation. Use this form to provide information or report circumstance changes. To
process this form, your signature is required on the reverse side.
IDENTIFICATION INFORMATION
This section MUST be completed. Check any box to indicate changed item(s). If your name has changed, provide
new and previous names.
Name _______________________________________________________________________________
Street Address ________________________________________________________________________
City, State, Zip Code ___________________________________________________________________
Home Telephone Number (
) ____________________________
Work Telephone Number (
) ____________________________
Social Security Number _________________________________
EDUCATION INFORMATION
Check any box to indicate changed item(s). Enter dates as mm/dd/yy.
Nursing program withdrawal date _________________________
College withdrawal date _________________________________
Continuing enrollment, but in different nursing program (e.g., from associate to bachelor degree)
Specify ____________________________________________
Continuing at least half-time enrollment in nursing or non-nursing studies.
Change in graduation date from: ___________ to: ___________
Transferred from: ________________________to: ________________________
For transfer students, awards depend on availability of funds at the new college.
Education Information Certification, to be completed by Dean, Registrar, or Academic Advisor.
I certify the above Educational Information to be accurate as reported.
Printed Name and Title of Certifying Official
College/University
Signature of Certifying Official
Date
EMPLOYMENT OBLIGATION
If an item applies to you, check the box and provide the required documentation.
Employed full time as a direct care nurse or as a teacher of nursing in Michigan.*
Employed part time as a direct care nurse or as a teacher of nursing in Michigan.*
Unable to work due to accident or illness.**
*Attach documentation from employer if working. Employer must document (on their letterhead) start date and whether
employed full or part time. Start date is defined as the date eligible employment began. Employment date must be 1)
After nursing program completed for which scholarship was received, and 2) After receiving nursing license.
**Attach documentation from physician if unable to work. Information must include situation description, dates, contact
phone numbers, addresses, and signatures.
Continued on page 2.
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