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U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
SERIAL
Indian Health Service
Public reporting burden for this collection of information is estimated to
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Officer, 801 Thompson Avenue, TMP Suite 450, Rockville, MD 20852-1006,
ATTN: PRA (0917-0006). Do not return the completed form to this address.
FORM APPROVED:
O.M.B. No. 0917-0006
Expiration Date: September 30, TBD
ACADEMIC YEAR
2008–2009
2009–2010
2010–2011
APPLICATION FOR PARTICIPATION IN:
THE INDIAN HEALTH SERVICE SCHOLARSHIP PROGRAMS
3/8” spine
perf
ALL MATERIALS SUBMITTED BECOME THE PROPERTY OF THE FEDERAL
GOVERNMENT AND SHALL NOT BE RETURNED.
BEFORE COMPLETING THIS APPLICATION, READ THE ACCOMPANYING DIRECTIONS IN
THE INSTRUCTION BOOKLET.
• Answer all questions.
• Use a No. 2 lead pencil. Do not use ball-point or other pen.
• In each block, where required, place the needed information in the boxes
above the grid area. Then, in the column below each box containing a letter,
number, or symbol, blacken completely the circle containing the same letter, number,
or symbol. In cases where a box is to represent a space and contains no letter,
number, or symbol, blacken the empty circle at the top of that column.
• Make your marks heavy and black.
• Avoid stray marks and smudges. Erase incorrect marks completely.
• Do not staple, fold, bend, spindle, or mutilate this form.
Submit application in the enclosed envelope, directly to your IHS Area office.
Questions Regarding Application should be directed to:
Grants Management Officer
Grants Management Branch
Division of Acquisition and Grants Operations
801 Thompson Ave., TMP Suite 360
Rockville, MD 20852
U.S. GOVERNMENT PRINTING OFFICE:2007–TBD-TBD
159498-9
IHS-856 (3/07)
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1. DISCIPLINE OR PREREQUISITE TRACK (SEE INSTRUCTION BOOKLET):
2. YOUR FULL NAME (SEE INSTRUCTION BOOKLET).
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Jr.
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II
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FIRST AND MIDDLE NAMES (SKIP ONE SPACE BETWEEN NAMES).
PAGE 2
SECTION A: GENERAL
CODE
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A
SECOND LINE OF STREET ADDRESS ONLY (Leave blank if not applicable.)
3/8” spine
perf
/
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PAGE 3
3. STREET ADDRESS ONLY (SEE INSTRUCTION BOOKLET)
Do not use these grids for City, State, and ZIP code.
PAGE 4
4. CITY, STATE, AND ZIP CODE.
a. City (only)
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–
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Trust Territories
of the Pacific
Islands
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Canal Zone
Colorado
Connecticut
Delaware
District of
Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
ZIP Code
d. Area Office Code
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
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2
2
3
3
3
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9
9
9
9
9
9
9
Use these last four shaded
columns only if your ZIP code
is more than five digits.
5a. HOME TELEPHONE NUMBER
NUMBER
AREA CODE
56
57
58
59
60
61
62
5b. DAYTIME TELEPHONE NUMBER
NUMBER
AREA CODE
63
64
65
66
67
97
98
Aberdeen
Albuquerque
Alaska
Billings
Oklahoma
Tucson
Phoenix
Navajo
Portland
Nashville
California
Bemidji
INMED
Lumbee
0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
6. SOCIAL SECURITY NUMBER
(SEE PRIVACY ACT NOTIFICATION
STATEMENT IN INSTRUCTION BOOKLET)
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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1
1
1
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1
1
1
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1
1
1
1
1
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1
1
1
1
1
1
1
1
1
1
1
1
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9
9
3/8” spine
perf
c.
b. State
Blacken the appropriate circle.
PAGE 5
3/8” spine
perf
SERIAL
7. E-MAIL ADDRESS—THIS WILL BE THE PRIMARY METHOD OF COMMUNICATION.
PLEASE LIST AN E-MAIL ADDRESS THAT YOU WILL CHECK FREQUENTLY.
A
A
A
A
A
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A
A
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D
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E
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K
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K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
T
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
W
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
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7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
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8
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9
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9
9
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9
9
9
9
9
9
9
9
9
9
9
9
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
@
.
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_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
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_
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_
_
_
_
_
_
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_
_
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_
_
PAGE 6
13. Have you ever received Federal support under the
Scholarship Program for First-Year Students of
Exceptional Financial Need (EFN)? (Preferential
consideration will be given to otherwise eligible
applicants who are identified as previous
recipients of EFN Scholarships. Applicants
wishing to claim this preference must submit a
letter of verification from an official at the school
in which the EFN Scholarship was received.)
8. PLACE OF BIRTH (PLEASE PRINT).
CITY
STATE OR COUNTRY
9. Are you a citizen or national of the United States?
(Only U.S. citizens or nationals are eligible to
receive Scholarship awards.)
BLACKEN the appropriate circle.
Yes
Yes
No
11. Tribal Code (Office Use Only)
0
0
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
5
5
5
5
6
6
6
6
7
7
7
7
8
8
8
8
9
9
9
9
14. PREVIOUS SERVICE COMMITMENT (SEE
INSTRUCTION BOOKLET).
Are you currently under any obligation to practice
your profession in a State or other entity upon the
completion of your professional training that would
conflict with the service obligation incurred under
this Scholarship?
Yes
No
(If you are obligated to practice under another
program, please read the terms of that agreement
carefully. Many agreements will enable you to serve
this Scholarship obligation first. If so, there is no
conflict and you should blacken the answer “No”.)
15. FUTURE SPECIALTY INTEREST (For Health Professions
Category Only)
(SEE INSTRUCTION BOOKLET, pg. 22, sec. A-14).
NAME OF SPECIALTY
12 . Tribal Recognition (mark the appropriate number)
Mark if you are an
Federally Recognized 1
CODE
enrolled member of a
Federally Recognized Tribe.
State Recognized
Descendent
2
3
If your tribe is STATE recognized, provide telephone
number and address of your state Attorney General’s
Office or commissioner of Indian Affairs.
TELEPHONE NUMBER
AREA CODE
(
)
–
ADDRESS
CITY
STATE
ZIP
A
N
A
N
A
N
A
N
A
N
A
N
A
N
B
O
B
O
B
O
B
O
B
O
B
O
B
O
C
P
C
P
C
P
C
P
C
P
C
P
C
P
D
Q
D
Q
D
Q
D
Q
D
Q
D
Q
D
Q
E
R
E
R
E
R
E
R
E
R
E
R
E
R
F
S
F
S
F
S
F
S
F
S
F
S
F
S
G
T
G
T
G
T
G
T
G
T
G
T
G
T
H
U
H
U
H
U
H
U
H
U
H
U
H
U
I
V
I
V
I
V
I
V
I
V
I
V
I
V
J
W
J
W
J
W
J
W
J
W
J
W
J
W
K
X
K
X
K
X
K
X
K
X
K
X
K
X
L
Y
L
Y
L
Y
L
Y
L
Y
L
Y
L
Y
M
Z
M
Z
M
Z
M
Z
M
Z
M
Z
M
Z
3/8” spine
perf
0
1
No
No
10. Are you an American Indian or Alaska Native?
Those eligible for scholarship awards are
applicants who are identified as American Indians
or Alaska natives. Applicants wishing to claim this
preference must submit with their application
supporting documentary evidence from the
Bureau of Indian Affairs or the Department of the
Interior or from their tribal organization.
Consideration is given only to those applicants
who qualify for priority selection as stated in the
Instruction Booklet.
0
Yes
PAGE 7
16. Print name, permanent address, and telephone
number of the person through whom you can
always be located (e.g., parent, relative, etc.)
SECTION B:
DEGREE PROGRAM
NAME
Your answers to this section should pertain only to
the scholarship for which you are applying.
ADDRESS
CITY
STATE
ZIP CODE
AREA CODE
PHONE NUMBER
1. Will you be enrolled as a full-time or part-time
student for the academic year for which you are
applying? (You must remain full-time or
part-time for the full academic year.)
Full-time
17. EMPLOYEE’S WITHHOLDING ALLOWANCE
CERTIFICATE (FORM W-4).
(SEE INSTRUCTION BOOKLET)
Based on Page 1 of the Internal Revenue Service (IRS)
Form W-4 accompanying the application packet,
please supply the following information:
3/8” spine
perf
a.
Single
Married
Married, but withhold at higher single rate
b. Total number of allowances claimed on Form
W-4, page 1, item 5.
0
1
2
3
4
5
7 or more
6
Part-time
Indicate the average number of credit hours
(e.g., PT = 6 to 11, FT = 12 or more) you will
be enrolled for the term, quarter or semester.
Full-time
Part-time
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
5
5
5
5
6
6
6
6
7
7
7
7
8
8
8
8
9
9
9
9
2. Print name of school in which you are enrolled
or accepted for enrollment.
SCHOOL
c. Are you claiming exemption from withholding
on Form W-4, page 1, item 7?
Yes
No
3. Print location of school.
CITY
d. Additional amount, if any, to be deducted each
pay period. Enter amount from Form W-4,
page 1, item 5. Indicate whole dollars only.
$
EXAMPLE: $30.00, Enter
$030 in the boxes above
the grid and blacken the
circles below.
4. School code (Office Use Only)
0
0
0
1
1
1
2
2
2
0
0
0
0
3
3
3
1
1
1
1
4
4
4
2
2
2
2
5
5
5
3
3
3
3
6
6
6
0
0
0
4
4
4
4
7
7
7
1
1
1
5
5
5
5
8
8
8
2
2
2
6
6
6
6
9
9
9
3
3
3
7
7
7
7
4
4
4
8
8
8
8
9
9
9
9
$
030
STATE
PAGE 8
5. Indicate the month and year you first attended or
will attend school.
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
5
5
5
5
6
6
6
6
7
7
7
7
8
8
8
8
9
9
9
9
Health Professions Preparatory
For students who are applying for
scholarships in any preparatory course of
study but pre-medicine or pre-dentistry.
Health Professions Pregraduate
For students who are applying for
scholarships in pre-medicine or
pre-dentistry ONLY.
Health Professions
6. In which of the following categories will you be charged
tuition and fees for the school year in which you are
applying for a scholarship?
8. What YEAR of Health Professions coursework will you be enrolled in
during the academic year for which you are applying for a scholarship?
9. EDUCATION
1st year
4th year
2nd year
5th year
3rd year
6th year
COLLEGE OR UNIVERSITY
If you have attended college or graduate school, please complete the following information showing your previous college
or university education. Attach official transcripts from each college/university.
NAME AND LOCATION OF COLLEGE OR UNIVERSITY
NAME
CITY
STATE
MONTH/YEAR ATTENDED
FROM
TO
NUMBER OF
TYPE OF
MONTH/YEAR
CREDITS
DEGREE
THAT DEGREE
COMPLETED (BA, MS, ETC.) WAS OBTAINED*
1.
2.
3.
4.
5.
*If graduating within 6 months, give month/year of expected degree.
HIGH SCHOOL OR G.E.D.
If you have not attended college, please complete the following. Write the name and location (City and State) of the high
school you attended or where you obtained your GED high school equivalency. Attach an official copy of your high school
transcripts or GED certificate with scores.
NAME AND LOCATION OF HIGH SCHOOL OR WHERE G.E.D. WAS OBTAINED
NAME
1.
2.
CITY
STATE
MONTH/YEAR ATTENDED
FROM
TO
HIGH SCHOOL
GRADUATION DATE
(MONTH/YEAR)
G.E.D.
CERTIFICATION DATE
(MONTH/YEAR)
3/8” spine perf
Resident/In-state
Non-resident/Out-of-state
School charges same tuition and
fees regardless of resident status
For students who are applying for
scholarships to support them in a
health professional school.
7b. IMPORTANT: Indicate the month and year.
Be sure to darken in the month and year of
your expected completion of the required
coursework or graduation date:
JANUARY
20
FEBRUARY
0 0 0 0
MARCH
1 1 1 1
APRIL
2 2 2 2
MAY
3 3 3 3
JUNE
4 4 4 4
JULY
5 5 5 5
AUGUST
6 6 6 6
SEPTEMBER
7 7 7 7
OCTOBER
8 8 8 8
NOVEMBER
9 9 9 9
DECEMBER
SERIAL
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
7a. I am applying for the following scholarships.
PAGE 9
SECTION D:
CERTIFICATION
SECTION C:
MISCELLANEOUS
1. Date of Birth (Month-Day-Year; e.g., February 5,
1974 would be written as 02-05-74)
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
4
4
4
4
4
4
5
5
5
5
5
5
6
6
6
6
6
6
7
7
7
7
7
7
8
8
8
8
8
8
9
9
9
9
9
9
I certify that the information given in this application
is accurate and complete to the best of my knowledge
and belief. I understand that it may be investigated
and that any willfully false representation is sufficient
cause for the rejection of this application, or, if
awarded a Scholarship, that I am liable for repayment
of all awarded funds and, further, that any false
statement herein may be punished as a felony under
U.S. code, Title 18, Section 1001.
SIGN YOUR FULL NAME IN INK AND DATE
SIGNATURE
DATE
2. Gender
3/8” spine
perf
Male
Female
3. If you do not receive a scholarship from the Indian
Health Service (IHS) may the IHS forward your
application to another funding source (e.g.,
non-governmental, tribal or other government
agencies)?
Yes
No
4. Grant Number (Office Use Only)
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
4
4
4
4
4
4
5
5
5
5
5
5
6
6
6
6
6
6
7
7
7
7
7
7
8
8
8
8
8
8
9
9
9
9
9
9
FOR
OFFICE
USE
ONLY
COM
INC
APL
LOA
TRA
IND
EVL
NAR
DBT
W-4
CUR
CON
EXP
0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
PAGE 10
SERIAL
3/8” spine perf
3/8” spine
perf
PAGE 11
PAGE 12
SERIAL
3/8” spine perf
| File Type | application/pdf |
| File Title | 159498-9 pgs. 1–4 |
| File Modified | 2007-12-04 |
| File Created | 2007-06-07 |