VA Form 10-0491a HPSP/VIOMPSP Addendum to Application

OMB Number: 2900-XXXX
Estimated Burden: 10 minutes
Health Professional Scholarship Program (HPSP) &
Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)

Addendum to Application
PRIVACY ACT NOTICE
The VA is asking you to provide the information on this form under the authority of 38 U.S.C. 7502 and 7602 in order for VA to determine the applicant's eligibility to
receive a scholarship award. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information for:
civil or criminal law enforcement; congressional communications; the collection of money owed to the United States; litigation in which the United States is a party or has
interest; the administration of VA training and scholarship programs, including verification of the applicant's eligibility to participate; and personnel administration. You do
not have to provide this information to VA but, if you do not, VA may be unable to process the applicant's request for a scholarship. If you give VA a social security
number, VA will use it to obtain information relevant to determining whether to grant a scholarship, and to administer the applicant's scholarship, if awarded. It also may be
used for other purposes authorized or required by law.

If there are any changes in CGPA, admission status, enrollment status, plan of study, projected costs, or program accreditation,
immediately forward this ADDENDUM along with supporting documentation to:
HPSP/VIOMPSP
Department of Veterans Affairs
1250 Poydras Street, Suite 1000
New Orleans, LA 70113
Name of Applicant (Last, First, MI):

SSN:

Name of college or university where applicant is enrolled/accepted (Do Not Abbreviate):
Reason for addendum:
Cumulative Grade Point Average change

Admission status change

Enrollment status change

Projected cost change

Plan of Study change

Other:

Program accreditation change

Comments/New Information:

Certification of Accuracy
I certify the accuracy of all information stated on this Form.
(Inaccurate data may cause both the school and the student to lose funding.)

Name (Print)

Signature (Dean/Program Director/Administrative Chair of Program)

Title

Phone Number (include area code)

VA FORM 0491A
10/19/12

Date

E-mail Address
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