Agonmjc Form 2171-R - Request For New Mexico Army National Guard Tuition Scholarship Funding
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2REQUEST FOR NEW MEXICO ARMY NATIONAL GUARD TUITION SCHOLARSHIP FUNDING
page 1 of 2
(NMNGTSP)
AUTHORITY: Section 21-1-2.1 NMSA 1979 (Laws 1996, Chap 64) Section 20-4-13 NMSA 1978 (Laws 1987, Chap 318)
PRINCIPAL PURPOSE(S): Application for and documentation of Tuition Scholarship funding only from the State of New Mexico
ROUTINE ISSUES: Used as a record of courses for which the service member is receiving tuition scholarship funding
DISCLOSURE: Disclosure of information is mandatory. AGONMJC form 2171-R is the only authority which can be used for obligation
of funds for the New Mexico National Guard Tuition Scholarship Program.
ANY APPLICATION NOT COMPLETED IN ITS ENTIRETY WILL BE RETURNED WITHOUT PROCESSING!
SEMESTER DEADLINES
FALL SEMESTER- 1 AUGUST / SPRING SEMESTER- 15 DECEMBER / SUMMER SEMESTER 15 MAY
APPLICANTS WILL COMPLETE ITEMS 1 THROUGH 9B AND SIGN AND DATE ON PAGE 2 (Appendix B)
1. APPLICANT’S NAME (last, first, MI)
2. SSN
3. ETS (Separation Date)
4. CREDITS EARNED
5. RANK/GRADE
6. ORGANIZATION / UIC (ARNG)
7. STUDENT CURRENT MAILING ADDRESS
8. NAME OF SCHOOL
8A.
8B. EDUCATIONAL GOAL (X box to left of goal that applies)
LOC. OF SCHOOL
AA/AS
BA/BS
Technical Cert.
ETP
9. PROJECTED
9A. PROJECTED TITLE OF COURSE
9B. # OF SEM/
9C. PER SEM / QTR
9D. TOTAL CLASS
COURSE #
QTR HRS
HOURS COST
COST (exact cost)
$
$
TOTALS
9E.
9F. $
9G. $
10. COURSE START DATE
10A. COURSE END DATE
10B. GUARD STATUS (X all that apply)
AIR GUARD
TECH
IDT
10C. CERTIFY THE FOLLOWING (x all that apply):
ARMY GUARD
AGR
SMP
Eligible or utilizing NM Lottery scholarship:
YES
NO
10D. List all Scholarships or GI Bills (Not tuition related):
Received Prior State Tuition Assistance:
YES
NO
On Academic Probation(1.9 GPA or below):
YES
NO
Funds being recouped for prior semester:
YES
NO
10E. List amount of all tuition related funding not NMNGTSP:
Receiving CH 33; Post 9/11 GI BILL
YES
NO
payment
11. NAME OF UNIT CDR (only)
11A. SIGNATURE
11B. DATE
ND
STUDENT SIGNATURE IS REQUIRED ON 2
PAGE OF APPLICATION FOR PROCESSING
12. NAME OF ESO OR AUTH REPRESENTATIVE
12A. SIGNATURE
12B. DATE
(ESO)
13. FUNDING APPROVAL BY
13A. SIGNATURE
13B. DATE
(TA Mngr)
AGONMJC FORM 2171-R, 01 October 2014. Supersedes 17 December 2012 Version
This form ratified by the ESO/Auth Rep and Fiscal Approving authority creates a binding obligatory document between the NMARNG and the Institution of higher
learning (IHL). IHL’s should send invoice to: DEPARTMENT OF MILITARY AFFAIRS, NMARNG-Education, Santa Fe, NM 87508.
AGONMJC 621-5
01 October 2014
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