VA Form 10-0491j HPSP/VIOMPSP Request for Deferment for Advanced Educatio

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

Request for Deferment for Advanced Education
A participant may request a deferment of obligated service to complete an approved program of advanced clinical training.
This document represents a request from you to delay the start of your Department of Veterans Affairs service obligation.
Return the completed form to:
HPSP/VIOMPSP
Department of Veterans Affairs
1250 Poydras St., Suite 1000
New Orleans, LA 70113.
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 administer your 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 your 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 continue your scholarship award. If you give VA your social security number, VA will use it to obtain
information relevant to administering your scholarship award. It also may be used for other purposes authorized or required by law.

HPSP

VIOMPSP

Participant's Name (Last, First, Middle):

Social Security Number:

Address (Include Street Address, City, State, and ZIP Code):

Phone Number:

Email Address:

Type of advanced clinical program you wish to attend:

Length of program:

Is your selection for this advanced clinical program
through a national match program?

If yes, title of the match program:

Yes

Program start date:

Anticipated date available for service obligation:

What is the notification date?:

No

Are all match sites/locations that you have applied to
accredited by the nationally recognized accrediting
body?
Yes
No

Name of accrediting body:

Name and location of advanced clinical site if known:
Name, address and telephone number (other than your own) of a person through whom you may always be reached:
Name of Secondary Contact (Last, First, Middle):

Phone Number:

Address (Include Street Address, City, State, and ZIP Code):

If you have any questions please contact the Department of Veterans Affairs, Healthcare Retention and Recruitment Office at
(504) 565-4900 or HRROScholarshipTeam@va.gov

Signature
VA FORM 0491J
10/19/12

Date
PAGE 1 of 1