Form IHS-816 Address Change Notice

OLD ADDRESS:

PRINT NAME:

INDIAN HEALTH SERVICE
IHS SCHOLARSHIP PROGRAM

City:

City:

MIDDLE

(Number)

LAST

Zip Code:

(Number)

Zip Code:

Address Change NOTICE

State:

FIRST

Telephone: (Area Code)

NEW ADDRESS:

State:



I have applied, but have not been
notified of the status of my application.
I already have an IHS scholarship.
I am in postgraduate training.
I am fulfilling my service obligation.

(Please fold on dotted line and tape closed on all three sides)

Telephone: (Area Code)
EFFECTIVE DATE OF

CHANGE:

Check Appropriate Box

SIGNATURE:

IHS-816 (Front)

06-0793e

Enter YOUR complete mailing address on the IHS SCHOLARSHIP
PROGRAM mailing card (below), tear along perforated line, and
place in Application Package (refer to instructions).
Do NOT mail the card.

The Address Change Notice (IHS-816) card should be
retained for future use.

(

PLEASE PRINT NAME AND ADDRESS

DEPARTMENT OF
HEALTH & HUMAN SERVICES
Indian Health Service
Rockville, MD 20852
Official Business
Penalty for Private Use $300

IHS SCHOLARSHIPS
IHS-815

+

DEPARTMENT OF
HEALTH & HUMAN SERVICES
Indian Health Service
Rockville, MD 20852
Official Business
Penalty for Private Use $300

PERMIT NO. 2787

ROCKVILLE MD

BUSINESS REPLY MAIL
POSTAGE WILL BE PAID BY ADDRESSEE

FIRST CLASS MAIL

Indian Health Service
IHS Scholarship Program
801 Thompson Ave., Suite 120
Rockville MD 20852-9736

/208529736/2

NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES

Your application for an
INDIAN HEALTH SERVICE SCHOLARSHIP
has been received by this office.

Acknowledgement of Receipt of Application

Indian Health Service
IHS Scholarship Program
801 Thompson Ave., Suite 120
Rockville, MD 20852

Please notify this office of changes in address or telephone.
You may be contacted by the IHS Scholarship Program should
further information be needed.

IHS-815