ish form 856-5

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

PUBLIC LAW 94-437—TITLE I SCHOLARSHIP PROGRAM
REASONS FOR REQUESTING SCHOLARSHIP
APPLICANT’S NAME

SOCIAL SECURITY NUMBER

FORM APPROVED:
OMB Approval No. 0917-0006
Exp. Date: 9/30/2007
See Estimated Average Burden Time
per Response on Reverse Side.

CAREER CATEGORY

EMAIL ADDRESS

INDIAN HEALTH SERVICE OFFICE APPLYING THROUGH

Explain why you are requesting this scholarship **

State your career goals **

Explain how these goals will help to meet the health needs of the Indian people **

** If more space is required, use back of last page of application or full sheets, the same size as this page. Write on each sheet
your name and social security number. Securely attach all sheets to this application.
IHS-856-5
(Rev. 5/07)

EF

ATTACHMENT III (Continued)

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 45 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).