Dd Form 2753 - Nsep Service Agreement Report For Scholarship And Fellowship Awards Page 2
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1
2SECTION III - DESCRIPTION OF SERVICE
13. NUMBER OF HOURS 14. TYPE OF EMPLOYMENT (X one)
12. DATES
PER WEEK
a. FEDERAL
a. FROM (MM/DD/YYYY)
b. TO (YYYYMMDD)
c. CONTRACTOR
b. EDUCATION
d. ACTIVE DUTY MILITARY
15. SUPPLEMENTAL INFORMATION (X all that apply)
a. I use a foreign language in my position. (Explain:)
b. My position requires a security clearance. (If so, type:)
16. DESCRIPTION OF DUTIES (Please spell out all acronyms.)
a. DEPARTMENT/ORGANIZATION
b. BUREAU/AGENCY
c. OFFICE
d. TITLE
INSTITUTION
e. Describe the work you are doing to fulfill your NSEP service requirement and how it relates to U.S. national security. If you are eligible to
work in higher education and are doing so, describe the connection with your NSEP-funded study.
SECTION IV - CERTIFICATION
(NOTE: Service will NOT be approved without supervisor verification and signature.)
17. I have activated and updated my resume on NSEPNET.
a. YES
b. NO
18. CONTACT INFORMATION FOR EMPLOYING ORGANIZATION
b. SUPERVISOR'S TELEPHONE NUMBER (Include area code)
a. NAME OF EMPLOYING ORGANIZATION
c. STREET ADDRESS
d. CITY
e. STATE
f. ZIP CODE
g. SUPERVISOR'S EMAIL ADDRESS
19. SUPERVISOR VERIFICATION
a. SUPERVISOR'S NAME (Last, First, Middle Initial)
b. TITLE
c. SUPERVISOR'S SIGNATURE
d. DATE SIGNED
20. I certify, to the best of my knowledge, that all of the above statements are true, complete, and correct. I agree to provide
additional information as requested. I understand that my service requirement is completed upon receipt of written
notification from NSEP. I agree to submit this form annually until my service is complete, or every six months if granted an
extension. I will notify NSEP within 10 days if my contact information changes.
a. NAME
b. SIGNATURE
c. DATE SIGNED
SECTION V - FOR NSEP USE ONLY
21. ACTION
22.a. NAME OF NSEP OFFICIAL
b. SIGNATURE
c. DATE SIGNED
23. LENGTH OF
24. MONTHS PREVIOUSLY
25. APPROVED
26. MONTHS
27. YEAR OF
28. (X)
REQUIREMENT
APPROVED
MONTHS
REMAINING
AWARD
S
LF
F
EHLS
DD FORM 2753 (BACK), NOV 2014
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