ihs-856-2

FORM APPROVED:
OMB Approval No. 0917-0006
Exp. Date: 9/30/2007

DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
INDIAN HEALTH SERVICE

See Estimated Average Burden Time
per Response on Reverse Side.

PUBLIC LAW 94-437—TITLE I SCHOLARSHIP PROGRAM
ACADEMIC YEAR 2008-2009 APPLICATION CHECKLIST

The applicant must complete and forward this sheet with the application and required documents.
Please check the appropriate box for each document which is enclosed.
APPLICANT’S NAME

CAREER CATEGORY

SOCIAL SECURITY NUMBER

INDIAN HEALTH SERVICE OFFICE APPLYING THROUGH

HAVE YOU EVER RECEIVED AN IHS SCHOLARSHIP OR GRANT?
If “Yes”, enter below:
CAREER CATEGORY

TYPE OF APPLICATION:

Yes

No

SECTION
New
Continuing
Health Preparatory
Pregraduate

Health Professions

ALL APPLICANTS:

NEW

1. Application Checklist ...................................................................................................
2. Application Form IHS-856 ...........................................................................................
3. Letter of Acceptance from College/Proof of Application to
Health Professions Program (Applicable to continuation
students who are transferring schools, changing from
103/103P to 104, or changing disciplines) ..................................................................
4. Official Transcripts for All Colleges
Cumulative GPA: Applicant’s Calculation: ______ ......................................................
5. Documentation for American Indian/Alaska Native Eligibility .....................................
6. Two Faculty/Employer Evaluations with original signatures .......................................
7. Reason for Requesting Scholarship ...........................................................................
8. Delinquent Debt Form .................................................................................................
9. W-4 Form with original signature ................................................................................
10. Course Curriculum Verification with original signature (If part-time—
minimum of six credit hours) .......................................................................................
11. Acknowledgment Card ................................................................................................
12. Curriculum for Major ....................................................................................................

HEALTH PROFESSIONS APPLICANTS ONLY:
13. Health Related Experience (MPH Only) – Optional Form ..........................................

I verify the application is complete.
APPLICANT’S SIGNATURE

IHS-856-2
(Rev. 5/07)

DATE

EF

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 8 minutes
per response including time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection
of information. An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it display 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: Indian Health Service, OPHS/DHPS/Scholarships Branch, 801 Thompson Avenue, TMP Suite 450, Rockville,
MD 20852, ATTN: PRA (0917-0006).