Form IHS-856-2 Application Checklist

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

FORM APPROVED:
OMB Approval No. xxxx-xxxx
Exp. Date: x/xx/xxxx
See Estimated Average Burden Time
per Response on Reverse Side.

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

APPLICATION CHECKLIST
The applicant must complete and forward this checklist with their application and required supporting documentation.
Please check the appropriate box for each document which is enclosed.
APPLICANT’S NAME

CAREER CATEGORY

SOCIAL SECURITY NUMBER

IHS AREA OFFICE

EMAIL ADDRESS

HAVE YOU EVER RECEIVED AN IHS SCHOLARSHIP OR GRANT?

If “Yes”, enter below:

CAREER CATEGORY

WHAT ACADEMIC YEAR ARE YOU APPLYING FOR? 20

Yes

No

– 20

I AM APPLYING FOR:

Preparatory Scholarship Program

Pre-Graduate Scholarship Program

Required Forms:

Health Professions Scholarship Program
Online Option

1. Application Checklist (IHS-856-2)

2. Application Bubble Sheet (IHS-856)

3. Documentation for AI/AN Eligibility (Form BIA-4432)

4. Two Faculty/Employer Evaluations (IHS-856-3)

Submitted Online

5. Narrative Statements (IHS-856-4)

Submitted Online

6. Delinquent Federal Debt (IHS-856-5)

7. F
 ederal Income Tax Withholding (Form W-4)

Print Option

Submitted Online

Go to www.irs.gov to download the form for the fall semester
of the academic year for which you are applying.

8. Course Curriculum Verification (IHS-856-6)

9. Acknowledgment Card (IHS-815)

Submitted Online

Required Documentation:

10. L
 etter of Acceptance from a College/University or
Proof of Application to a Health or Allied Health Professions Program

11. O
 fficial Transcript(s):

All College(s)/University(s)
High School or Home School Equivalent
General Education Development (GED)
Official Use Only — Cumulative GPA : Area Scholarship Coordinator Calculation:

12. C
 urriculum for Major

Attach this documentation with your Course Curriculum Verification form.

13. C
 omplete photocopy set

Faculty/Employer Evaluations and Official Transcripts will be copied by
IHS Scholarship Program staff

I verify the application is complete, with all required forms, supporting documentation and original signatures.
APPLICANT’S SIGNATURE

IHS-856-2

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 displays 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, IHS Scholarship Program, 801 Thompson Ave.,
TMP-450, Rockville, MD 20852.