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Form Under Review
Expiration Date: xx/xx/xxxx
Section A
Section A.
1.
Please answer these general questions.
Tell us why you are submitting this application. (You may check more than one box.)
Initial Certification. This is a request for initial approval to participate in federal student
financial aid programs and to be initially designated as an eligible institution for other Higher
Education Amendments (HEA) programs.
Change in institutional ownership or structure. This is a request to participate in federal
student financial aid programs and to be designated as an eligible institution for other HEA
programs following a change in institutional ownership or structure.
Check here if requesting a preacquistion review.
Recertification. This is a request to continue to participate in federal student financial aid
programs and to continue to be designated as an eligible institution for other HEA programs
either in response to a recertification notice from us or because your institution’s Program
Participation Agreement (PPA) will expire soon.
Designation as an eligible institution. This is a request to be designated as an eligible
institution so that your students may receive deferments under federal student loan programs, so
that your institution may apply to participate in federal HEA programs, including the Title IV
student financial aid programs, or so that your students may claim an education tax credit such as
the American Opportunity Tax Credit or Lifetime Learning Credit.
Reinstatement. This is a request to be reinstated to participate in federal student financial aid
programs and/or to be redesignated as an eligible institution for other HEA programs.
Update Information. The purpose of this application is to update information about the
institution. If you check “Update Information,” please identify at least one purpose.
Other (specify)
2.
What is the name of your institution?
1
Section A
3a.
Do you have another name such as a trade name or a d/b/a name, under which you legally do
business as a postsecondary educational institution?
Yes
No
If yes, what is that name?
3b.
During the last 4 years, have you had another name that you have not previously reported
to the Department of Education?
Yes
No
If yes, what is that name?
4.
Check here if you are an institution resulting from a merger in the past four years
that you have not previously reported to the Department of Education, and give the
names, TIN Numbers, and OPE ID numbers of the former (pre-merger) institutions.
(You must enter the merger date in Question 19 (Section C)).
OPE ID
5.
Name
TIN
What is your 8 digit OPE ID Number? (Enter the first 6 digits. The final 2 digits are entered for you.)
Check here if you are an initial applicant and do not have an OPE ID number, and go to
Question 6.
Current OPE ID (or former OPE ID if seeking reinstatement)
00
2
Section A
6a.
What is your 9-digit Tax Identification Number (TIN) assigned by the IRS?
6b.
What is your 9-digit DUNS number?
7.
8.
9.
What was your most recently completed award year?
Beginning date:
07/01/____
Ending date:
06/30/____
What is your current award year?
Beginning date:
07/ 01/____
Ending date:
06/30/____
(Optional) Does your institution have a website (or home page) on the Internet?
Yes
No
If yes, list the electronic address (URL).
10.
Who is your chief executive officer (CEO)/president/chancellor?
First name, MI, Last name, Suffix
(include prefix, such as Mr., Ms., Dr.)
Job Title
Business street address
City
3
Section A
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address
11.
Who is your chief fiscal officer/financial officer?
First name, MI, Last name, Suffix
(include prefix, such as Mr., Ms., Dr.)
Job Title
Business street address
City
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
4
Section A
E-mail address
12.
Who is your chief financial aid director?
NOTE: This must be a capable individual designated to be responsible for administering all the Title IV, HEA programs
and coordinating those programs with the institution's other Federal and non-Federal programs of student financial
assistance.
(See 34 CFR 668.16)
First name, MI, Last name, Suffix
(include prefix, such as Mr., Ms., Dr)
Job Title
Business street address
City
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address
5
Section A
13.
To whom do you wish us to send publications (such as the FSA Handbook) and printed communications
concerning federal student financial aid?
Check here if this is the same person as in Question 10.
Check here if this is the same person as in Question 12.
If neither of these people, complete the information below.
First name, MI, Last name, Suffix
(include prefix, such as Mr., Ms., Dr.)
Job Title
Mailing address
City
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address
6
Section A
14.
Whom should we contact if we have questions about information in this form? (Note: If there is
someone you wish us to contact outside of your institution, you may enter them in question 70.)
Check here if this is the same person as in Question 10.
Check here if this is the same person as in Question 12.
If neither of these people, complete the information below.
First name, MI, Last name, Suffix
(include prefix, such as Mr., Ms., Dr.)
Job Title
Business street address
City
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address
7
Section B
Section B. Please tell us about your accreditation
and state authorization to provide
postsecondary education.
Check here if you are a foreign institution (including foreign graduate medical schools), and go to
Section C.
15.
What is your accrediting agency?
If you have institution-wide accreditation, provide the following information for each agency. If more than
one accrediting agency provides accreditation, designate the one you wish us to use in determining your
eligibility and continued eligibility (the Primary accreditor).
If you do not have institution-wide accreditation, provide the following information for each accrediting
agency that either accredits a program that is currently eligible or for which you are seeking eligibility.
(This includes programs such as a hospital-based nursing program or radiologic technology program.)
You must include a copy of your current letter of accreditation.
Abbreviation of accrediting agency (A list of abbreviations accompanies this application.)
• What year did your accrediting agency last accredit you?
• For how many years is this accreditation granted?
Check here if this is your primary accreditor
Check here if this is an Institution-wide Accreditor
Check here if this is a Programmatic Accreditor
Provide the End Date if you are no longer accredited by this agency.
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet, repeat
the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for each question.
Insert continuation sheets following the page where the question is asked.
You must show current accreditation or give an explanation in Question 69 (Section K).
8
Section B
Check here if you do not offer a flight program, and go to Question 17.
16.
If you offer a flight program, provide your U.S. Federal Aviation Administration (FAA)
Part 141 certification number.
Number
Date FAA certification expires
(mm/dd/yyyy format)
17.
What state agencies authorize or license you to provide postsecondary educational programs?
(For this question, do not include educational programs that are provided at “distance learning” sites.)
a.
Check here if you are a public institution and do not provide at least 50% of
an educational program outside your state, and go to Section C.
b.
Check here if you are a public institution and you do provide at least 50% of an
educational program outside your state, and list (for each state other than your
“home” state) each state agency that licenses you, or otherwise provides you with
legal authority, to provide postsecondary educational programs.
c.
Check here if you are a private institution, and list each state agency that licenses
you, or otherwise provides you with legal authority, to provide postsecondary
educational programs.
d.
Check here if you or your programs are not required to be authorized or licensed by
a state agency, and include a copy of the basis for that determination.
Agency Name
Business street address
City
9
Section C
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address (if applicable)
You must include a copy of your current state license(s) or other state authorization(s)
and/or exemption(s).
Provide the End Date if you are no longer authorized by this agency.
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for
each question. Insert continuation sheets following the page where the question is asked.
Section C. Please describe your institutional
control and structure.
18. Check your type of institutional structure (check one).
Public institution
Private nonprofit 501(c)(3) institution
You must include a copy of your 501(c)(3) designation from the IRS.
For-profit institution
10
Section C
Foreign institution (check one)
Public institution
Private nonprofit institution
You must include a certified English translation of your
nonprofit designation status.
For-profit institution
(Note: Foreign graduate medical schools and foreign veterinary schools whose
students complete their clinical training at an approved veterinary school in the U.S.
are the only foreign for-profit institutions eligible to apply to participate in federal
student financial aid programs.)
19.
Check here if this is a request for initial certification, and go to Question 20.
For all other institutions, since you were last certified to participate in federal student
financial aid programs, has your institutional structure changed?
Yes
No
If yes, give the date of the change.
(mm/dd/yyyy format)
20.
Check here if you are a public institution, and go to Section E.
Check here if you are not a public institution, and list the names of your board of trustees or
your board of directors.
Check here if you have a board of trustees.
Check here if you have a board of directors.
Check here if you have more than 10 on your board, list only the board’s
executive committee, and provide the name of a contact person in Question 21.
11
Section C
First name, MI, Last name, Suffix
(include prefix, such as Mr., Ms., Dr.)
12
Section C
21
If you provide only the board’s executive committee in Question 20, tell us who is the
appropriate person to contact for further information about your board (for example, the board’s
recording secretary)?
Check here if this is the same person as in Question 10.
Check here if this is the same person as in Question 12.
If neither of these people, complete the information below.
First name, MI, Last name, Suffix
(include prefix, such as Mr., Ms., Dr.)
Job Title
Business street address
City
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address
13
Section D
Section D. If you are a for-profit institution, or are a notfor-profit institution with a change in control,
please answer these questions. (This includes
for-profit foreign graduate medical schools.)
Check here if this does not apply to you and go to Section E.
22 – 24 Provide information for each person or entity that directly or indirectly owns a 25% or greater interest in
your institution.
a. The owner or person is (check one):
a corporation (complete b. and c.)
Publicly traded - Provide the stock exchange trading symbol ___________
Closely held corporation
Subchapter S Corporation
Limited Liability Company
Other, identify _________________________
an unincorporated business entity (such as a partnership or trust) (complete b. and c.)
General partner/partnership
Limited liability
Voting trust
Other, identify _________________________
an individual (complete d.)
14
Section D
b.
Name of corporation or other business entity
Business street address
City
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address
Percentage of ownership
Date ownership began
TIN
Identify the state or country in which you are incorporated.
If you are a corporation, give the name and address of the contact person (sometimes known as the
“registered agent”) within the state or foreign country where you are incorporated.
First name, MI, Last name, Suffix
(include prefix, such as Mr., Ms., Dr.)
Job Title
15
Section D
Business street address
City
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address
c.
List the following information for each person, corporation, or unincorporated business
entity that directly or indirectly owns a 25% or greater interest in the corporate owner
or entity:
Name of owner
First name, MI, Last name, Suffix
(include prefix, such as Mr., Ms., Dr.)
Business street address
City
16
Section D
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address
Home address (for person owners)
City
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Percentage of ownership
Date ownership began
SSN or TIN (required)
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet, repeat the
question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for each question.
Insert continuation sheets following the page where the question is asked.
17
Section D
d.
If the owner is an individual, provide the following information.
First name, MI, Last name, Suffix
(include prefix, such as Mr., Ms., Dr.)
Business street address
City
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address
Home address
City
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Percentage of ownership
Date ownership began
18
SSN of owner (required)
Section D
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for each
question. Insert continuation sheets following the page where the question is asked.
25.
Has a person or entity listed in Question 24 or a member of that person's family or a director of your
institution owned 25% or more or held a position listed below of another institution that is now
participating in or ever participated in federal student financial aid programs or of a third-party servicer
listed in Question 58?
The ownership could be:
• individual, or
• held by one or more family members, or
• in combination with others, such as a voting trust.
The position held at another institution could be any of the following:
• member of the board of directors, or
• chief executive officer, or
• other executive officer, general partner or director of the institution or servicer.
Yes
No
If yes, what is the name of the owner (either the name of a person or an entity) or the director?
(If a person, include prefix, such as Mr., Ms., Dr.)
If applicable, what is the name of the third-party servicer that is or was owned, or where the
position was held?
If applicable, what is the name of the institution that is or was owned, or where the position was
held?
If applicable, what is the current or former OPE ID of this institution?
If applicable, when did ownership/position end?
19
Section D
Is there any liability currently owed to the Department that was established during the
period of ownership or position held? (If yes, please explain in Section K, Question 69)
Yes
No
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet, repeat
the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for each question.
Insert continuation sheets following the page where the question is asked.
20
Section E
Section E. Please provide the following information
for each educational program that you
are requesting be eligible to participate in
federal student financial aid programs.
26.
Please check each box that describes the educational programs that you provide as of the
date you submit this application or that you will provide during the current award year.
Provide information only on programs that you wish to be eligible for federal student
financial aid.
(You may check more than one box.)
Note: If a program is required to prepare a student for gainful employment in a recognized occupation, the
institution must be able to demonstrate a reasonable relationship between the length of the program
and the entry-level requirement for the recognized occupation for which the program prepares the
student. The Secretary considers the relationship to be reasonable if the number of clock hours
provided in the program does not exceed by more than 50 percent the minimum number of clock
hours required for training in the recognized occupation for which the program prepares the student,
as established by the State in which the program is offered, if the State has established such a
requirement, or as established by any Federal agency. If the program exceeds by more than 50
percent of the State or Federal minimum number of clock hours, please explain in Section K,
Question 69.
Note: Post-baccalaureate students pursuing prerequisite coursework (such as prerequisite courses for
medical school) have their eligibility determined on the basis of student eligibility for federal
student financial aid criteria rather than program eligibility criteria. Therefore, these types of
programs are not included here.
a.
associate degree programs
b.
bachelor’s degree programs
c.
master’s degree programs or doctoral degree programs
d.
first professional degree programs
Do you measure student's progress in any of these degree programs by direct assessment instead of credit
or clock hours?
Yes
No
e.
graduate or professional programs that
•
•
do not lead to a post-baccalaureate degree,
are at least 10 weeks, and
21
Section E
•
•
provide at least 8 semester or trimester credit hours, 12 quarter credit hours,
or 300 clock hours of instruction.
prepare students for gainful employment in a recognized occupation
f.
two-academic-year transfer programs (see glossary)
g.
undergraduate programs that
•
•
•
•
h.
lead to a certificate or other recognized educational credential,
prepare students for gainful employment in a recognized occupation,
are at least 15 weeks, and
provide at least 16 semester or trimester credit hours, 24 quarter credit hours, or
600 clock hours of instruction.
undergraduate programs that
•
•
•
•
•
i.
lead to a certificate or other recognized educational credential,
prepare students for gainful employment in a recognized occupation,
are at least 10 weeks, and
provide at least 8 semester or trimester credit hours, 12 quarter credit hours, or
300 clock hours of instruction,
AND
require an enrolling regular student to have an associate degree or higher degree.
undergraduate programs that
•
•
•
•
•
•
j.
lead to a certificate or other recognized educational credential,
prepare students for gainful employment in a recognized occupation,
are at least 10 weeks, and
provide at least 300 but not more than 599 clock hours of instruction,
do not exceed by more than 50% the minimum number of clock hours established
by the state for such training programs, and
have been provided for at least one year.
Post-baccalaureate teacher certification program
•
•
•
•
that consists of courses required by the state for students to receive initial
certification to teach in an elementary or secondary school in that state,
that does not lead to a graduate degree,
where the institution does not offer a bachelor’s degree in education, and
where the institution is not otherwise Pell Grant eligible.
22
Section E
k.
Comprehensive Transition and Postsecondary Program (for students with
intellectual disabilities - please refer to 34 C.F.R. 668.231 for information about
the requirements of this program)
Check here if you award an associate degree, bachelor’s degree, or higher degree to all
your students who successfully complete any of your programs.
27.
Based on the boxes checked in Question 26, please provide the following information for the
educational programs that you wish to be eligible for federal student aid.
a. If you checked box a. in Question 26, provide information about your associate degree
programs.
Name of program
CIP code (A list of CIP codes accompanies this application.)
Number of Weeks
Clock hours (number of hours) of instruction
Number of credit hours
Type of Hours (check one)
semester
trimester
quarter
clock
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate
sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as
appropriate for each question. Insert continuation sheets following the page where the question is asked.
23
Section E
b. If you checked box b. in Question 26, provide information about your bachelor’s degree
programs.
Name of program
CIP code (A list of CIP codes accompanies this application.)
Number of Weeks
Clock hours (number of hours) of instruction
Number of credit hours
Type of Hours (check one)
semester
trimester
quarter
clock
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate
sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as
appropriate for each question. Insert continuation sheets following the page where the question is asked.
c.
If you checked box c. in Question 26, provide information about your master’s and/or
doctoral degree programs.
Name of program
CIP code (A list of CIP codes accompanies this application.)
Number of Weeks
Clock hours (number of hours) of instruction
24
Section E
Number of credit hours
Type of Hours (check one)
semester
trimester
quarter
clock
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate
sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as
appropriate for each question. Insert continuation sheets following the page where the question is asked.
d. If you checked box d. in Question 26, provide information about your first professional
degree programs.
Name of program
CIP code (A list of CIP codes accompanies this application.)
Number of Weeks
Clock hours (number of hours) of instruction
Number of credit hours
Type of Hours (check one)
semester
trimester
quarter
clock
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate
sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as
appropriate for each question. Insert continuation sheets following the page where the question is asked.
25
Section E
e.
If you checked box e. in Question 26, provide information about your non-degree graduate
programs.
Name of program
CIP code (A list of CIP codes accompanies this application.)
Number of Weeks
Clock hours (number of hours) of instruction
Number of credit hours
Type of Hours (check one)
semester
trimester
quarter
clock
Check here if you need space to give more than one answer and continue on a separate sheet. On the
separate sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so
on as appropriate for each question. Insert continuation sheets following the page where the question is
asked.
f.
If you checked box f. in Question 26, provide information about your two-academic-year
transfer programs.
Name of program
CIP code (A list of CIP codes accompanies this application.)
Number of Weeks
Clock hours (number of hours) of instruction
26
Section E
Number of credit hours
Type of Hours (check one)
semester
trimester
quarter
clock
Check here if you need space to give more than one answer and continue on a separate sheet. On the
separate sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so
on as appropriate for each question. Insert continuation sheets following the page where the question is
asked.
g. If you checked box g. or h. in Question 26, provide information about your non-degree
undergraduate programs.
Name of program
CIP code (A list of CIP codes accompanies this application.)
Number of Weeks
Clock hours (number of hours) of instruction
Number of credit hours
Type of Hours (check one)
semester
trimester
quarter
clock
Is each course within the program acceptable for full credit toward your associate degree or
higher degree?
Yes
No
Check here if you need space to give more than one answer and continue on a separate sheet. On the
separate sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so
on as appropriate for each question. Insert continuation sheets following the page where the question is
asked.
27
Section E
h. If you checked box i. in Question 26, provide information about your non-degree
undergraduate programs.
Name of program
CIP code (A list of CIP codes accompanies this application.)
Number of Weeks
Clock hours (number of hours) of instruction
Maximum number of clock hours authorized by the state licensing agency
Completion rate*
Placement rate*
*Provide the completion rate and the placement rate for your most recently completed award
year. (Instructions on how to calculate the completion rate are found in 34 CFR 668.8(f).
Instructions on how to calculate the placement rate are found in 34 CFR 668.8(g).)
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate
sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as
appropriate for each question. Insert continuation sheets following the page where the question is asked.
i.
If you checked box k. in Question 26, provide information about your Comprehensive
Transition and Postsecondary Program.
Name of program
28
Section E
CIP code (A list of CIP codes accompanies this application.)
Number of Weeks
Clock hours (number of hours) of instruction
Number of credit hours
Type of Hours (check one)
semester
trimester
quarter
clock
Is each course within the program acceptable for full credit toward your associate degree or
higher degree?
Yes
No
ADDITIONAL INFORMATION REQUIRED: If not previously provided, the
institution must provide a detailed description of this Comprehensive Transition and
Postsecondary Program addressing all of the components of the program as defined in 34
C.F.R. 668.231. The institution must send this information as a pdf attachment to
FSA_PEPS@ed.gov.
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for
each question. Insert continuation sheets following the page where the question is asked.
28.
Do you contract with an organization or ineligible institution to provide more than 25% of any
educational program, (such as internship, externship, practicum in nursing, midwifery, medical
technician, etc.)?
Note: If you contract 50% or more of the program to an ineligible
institution or organization, the program is not eligible for Title IV.
Yes
No
29
Section E
a.
If yes, provide the following information.
Name of program
Name of organization or ineligible institution
Corporation name, if applicable
Business street address
City
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Former OPE ID number of the other institution, if applicable
What percent of the program is contracted out?
You must include a copy of the approval from your accrediting agency for contracting
this program.
b.
Check here if any owner or person listed in Question 24 or Question 25
directly or indirectly
• owns or controls 25% or more of the ineligible institution
or
• serves as a director or as an executive officer of the ineligible institution.
What is the name of this owner or person?
30
Section F
c. Did the ineligible institution withdraw from participating in federal student financial aid
programs under a termination, show cause, suspension, or similar type of proceeding
initiated by its state licensing agency, accrediting agency, guarantor, or the U.S. Secretary
of Education?
Yes
No
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for
each question. Insert continuation sheets following the page where the.
Section F.
29.
Please tell us about your locations.
What is your principal location?
Name of location
Business street address
City
County
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
30.
Provide the following information for any of your locations (other than your principal location)
that meet any one of these three criteria and at which you provide educational programs to students
whom you wish to participate in federal student financial aid programs:
or
or
It is a location where students could complete 50% or more of an educational program that
you offer during the current award year.
It is a location where students could complete at least 50% of an educational program
over a two-year period (consisting of the current award year and the most recently
completed award year).
It is a location where you provide any educational programs if, during the past twoyear period (consisting of the current award year and the most recently completed
award year), you told students that they could complete at least 50% of any
educational programs there.
31
Section F
Name of location
Business street address
County
City
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
OPE ID number of location or if no OPE ID number, check here
DUNS number
(Optional) Bradstreet
(If you do not have a DUNS number, you can contact Dun & Bradstreet
at 1-800-333-0505 to have a number assigned.)
Would you like to receive mailings from the Department at this location?
Yes
No
Check here if the mailing address is different from the address above, and
provide the mailing address below.
Mailing address
City
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Check here if you need space to give more than one answer and continue on a separate sheet. On the
separate sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3,
and so on as appropriate for each question. Insert continuation sheets following the page where the
question is asked.
32
Section G
Section G. Please tell us about your correspondence
courses, your students enrolled under
ability-to-benefit provisions, and your
incarcerated students.
31.
Are any of your programs offered in whole or part by correspondence or distance
education?
Note: Distance education is defined as education that is delivered to students who are separated from
instructors and is designed to ensure that there is regular and substantive interaction between
students and instructors, either synchronously or asynchronously.
Yes
32a.
No
For the most recently completed award year, were more than 50% of your courses
taught by means of correspondence? (See 34 CFR 600.7 and 668.38)
Note: If a course is offered through traditional methods and through correspondence, then that
course should be counted under both traditional methods and correspondence. Therefore, the
same course might be counted more than once.
Yes
32b.
For the most recently completed award year, were 50% or more of your regular students
enrolled in correspondence courses? (See 34 CFR 600.7, and 668.38)
Yes
33.
No
No
For the most recently completed award year, were more than 50% of your regular students
ability-to-benefit students? (See 34 CFR 600.7 and 668.32)
Note: Do not include students who are being educated at your institution under a specific
contract with federal, state, or local governments for training purposes (such as most
contracts under the Job Training Partnership Act)
Yes
34.
No
During the most recently completed award year, were more than 25% of your
regular students incarcerated? (See 34 CFR 600.2, 600.7, and 668.32)
Yes
No
33
Section H
Section H. Please complete this section if this is an
initial application or you were certified
but you have a change in your ownership
or structure, are seeking reinstatement,
or you want to add or drop a Title IV
program.
Check here if this is not an initial application or a change in ownership or
structure or for reinstatement, and go to Section I.
Note: Here “change in ownership or structure” refers to a change in ownership, conversion to or
from a non-profit institution, or a merger of two or more institutions.
If you acquired the institution or if the institution is the result of a merger of two
or more former institutions, you will be liable for any debts incurred by your
predecessors under federal student financial aid programs.
35.
Tell us why you are completing this section.
This is an initial application. Tell us on what date you were both legally authorized
to provide and began continuously providing the educational training program for
which you are seeking eligibility. Then, indicate below whether you are an
institution with or without history.
Month, Day, Year
Note: If you are a for-profit institution or if you offer
only a program(s) of less than one academic year,
you must have been in existence for at least two
years to be eligible to participate in federal
student financial aid programs
You are an institution without history. Answer Questions 36, 37, and
38, then go to Section I.
You are an institution with history (for example, you have been in operation
for one or two years). Answer all the questions in this section.
34
Section H
You are an institution with a change in your ownership. Answer Questions 36, 37, and
38, then go to Section I.
You are an institution that converted to a not-for-profit institution. Answer Questions
36, 37, and 38, then go to Section I.
You are an institution that converted to a for-profit institution. Answer Questions 36,
37, and 38 then go to Section I.
You are an institution resulting from a merger in the past four years. Answer Questions
36, 37, and 38 about the newly formed institution, then go to Section I.
You are an institution seeking reinstatement. Answer all the questions in this section.
36.
How many full-time equivalent (FTE) financial aid staff members do you have?
Administrative, counselors, or other professionals
FTE
Clerical
FTE
37.
Indicate all of the federal student financial aid programs in which you are seeking approval
to participate. (Note: Foreign institutions, including foreign graduate medical schools, may
apply only for the William D. Ford Federal Direct Loan Program (Direct Loan Program))
Federal Pell Grant Program
Federal Perkins Loan Program
Federal Supplemental Educational Opportunity Grant (FSEOG) Program
Federal Work-Study (FWS) Program
Federal Work-Study-regular or general
Job Location and Development (JLD)
Private-Sector Employment
35
Section H
Federal Family Education Loan (FFEL) Program- No Longer Available
(formerly called the Guaranteed Student Loan Program)
Indicate specific programs within FFEL for which you are seeking approval to participate.
Federal Stafford Loan Program (subsidized)
Federal Stafford Loan Program (unsubsidized)
Federal PLUS Loan Program (parent loans)
William D. Ford Federal Direct Loan Program (Direct Loan Program)
Indicate specific programs within the Direct Loan Program for which you are seeking approval
to participate.
Direct Subsidized Loan Program (Undergraduate level programs only)
Direct Unsubsidized Loan Program
Direct PLUS Loan Program
38.
Do you anticipate an increase of 10% or more in your student body in the next award year?
Yes
No
How many regular students do you estimate would be eligible to receive federal student
financial aid for the remainder of the current award year and each of the next two award
years if you become eligible to participate in federal student financial aid programs?
Estimated number for the remainder of the current award year
Estimated number for the next award year
Estimated number for the award year following the next award
year
39.
Provide the following information about your regular students. (If a student drops out
and then reenrolls, count the student each time.)
a. How many regular students were enrolled at your institution during your
most recently completed award year?
36
Section H
b. How many regular students in a. dropped out during the 100% refund period during
your most recently completed award year?
c.
40.
How many regular students in a. dropped out after the 100% refund period during
your most recently completed award year?
If you provide vocational programs, list all such educational programs (not classes):
that you have provided continuously for at least 24 months
and
for which you would like regular students to be eligible for federal student
financial aid.
Name of program (name should be consistent with Question 27)
Check here if you need space to give more answers and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as
appropriate for each question. Insert continuation sheets following the page where the question is asked.
37
Section I
Section I. If you are a foreign institution, please
complete this section. (This includes
foreign graduate medical schools.)
Check here if you are not a foreign institution, and go to Section J.
Note: If you are a foreign institution, you must include a copy of your most recent catalog and a
certified English translation (see glossary) of all sections dealing with degrees and programs
provided at your institution.
41.
Do you admit as regular students only people who have a credential of secondary school
completion or its recognized equivalent?
Yes
No
42.
In the country where you are located, are you legally authorized to provide an
educational program beyond the secondary school level?
Yes
No
If yes, what is the name and address of the agency or ministry within the country that
enforces this authority?
Name of office
Business street address
City
Foreign Province, Country, Postal Code
Telephone number (Complete international telephone number)
ext:
38
Section I
Foreign fax
ext:
E-mail address
Include a copy of your legal authorization and its certified English translation.
43.
Are you legally authorized to award a degree that is equivalent to an associate,
baccalaureate, graduate, or professional degree awarded in the United States?
Yes
No
Include a copy of your legal authorization and its certified English translation.
44.
Do you provide an educational program that is at least a two-academic-year program
acceptable for full credit toward the equivalent of a baccalaureate degree awarded in the
United States?
Yes
No
45.
Do you provide any educational programs that meet all three of these criteria?
•
The program is equivalent to at least a one-academic-year training
program in the United States.
and
•
The program leads to a certificate, degree, or other educational
credential that is equivalent to one offered in the United States.
•
The program prepares students for gainful employment in an
occupation that is equivalent to one in the United States.
and
Yes
46.
No
Do you have administrative offices and/or recruiting offices in the United States that represent
you?
Yes
No
39
Section I
If yes, provide the following information.
Name of U.S. administrative office
Business street address
City
State and Zip +4
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address
Name of contact person at the office:
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr. and suffix such as Jr., II)
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate
sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as
appropriate for each question. Insert continuation sheets following the page where the question is asked.
Check here if you are a foreign institution that is not a foreign graduate medical or
veterinary school and go to Section J.
40
Section I
47.
Where is the facility at which you provide graduate medical educational program instruction in
your country?
Name of facility
Address
City
Foreign Province, Country, and Postal Code
Telephone number (Complete international telephone number)
ext:
Foreign fax
ext:
E-mail address
Name of contact person at the facility:
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr. and suffix such as Jr., II)
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for
each question. Insert continuation sheets following the page where the question is asked.
41
Section I
48.
What entity in your country is legally authorized to evaluate the quality of your medical
educational program?
Name of entity
Address
City
Foreign Province, Country, and Postal Code
Telephone number (Complete international telephone number)
ext:
Foreign fax
ext:
E-mail address
Name of contact person at the entity:
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr. and suffix such as Jr., II)
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for
each question. Insert continuation sheets following the page where the question is asked.
42
Section I
49.
Are you approved by the entity listed in Question 48 to provide a graduate medical
educational program in your country?
Yes
No
Include a copy of each approval and its certified English translation.
50.
What is the length of the program of graduate clinical and medical instruction?
months
Is any part of your program of graduate clinical instruction provided in the United States?
51.
Yes
No
If yes, provide the following information.
a.
Name of facility
Business street address
City
State and zip+4
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address
43
Section I
Name of contact person at the facility:
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr. and suffix such as Jr., II)
b.
Part of program offered:
Classroom
Clinical
Do you provide the remainder of your program of graduate medical instruction in your country?
Yes
No
c.
What medical licensing boards and evaluating bodies in the United States currently approved
the clinical training in the United States?
d.
Was your clinical training program in the United States approved as of January 1, 1992 by
the state in which you offer it?
Yes
Include a copy of the approval.
No
If yes, is it currently approved by the state?
Yes
Include a copy of the approval.
No
Check here if you need space to give more than one answer and continue on a separate sheet. On the
separate sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and
so on as appropriate for each question. Insert continuation sheets following the page where the question is
asked.
44
Section I
52.
List the dates of graduation and the number of regular students who graduated within the past three
12-month periods.
Dates
Dates
Dates
Graduates
Graduates
Graduates
Check here if you need space to give more than one answer and continue on a separate sheet. On the
separate sheet, repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on
as appropriate for each question. Insert continuation sheets following the page where the question is asked.
53.
What are the beginning and ending dates of your institution’s most recently completed academic
year?
Beginning date
Ending date
54.
How many full-time regular students were enrolled during the most recently completed academic
year?
55.
How many of the regular students in Question 54 were not U.S. Citizens or residents eligible for
U.S. federal financial aid programs?
56.
If your school is located in Canada, go to Section J. During the most recently completed year,
how many of your regular students and graduates from the three preceding years took any
"step" of the examinations administered by the Education Commission for Foreign Medical
Graduates?
How many of these students received passing scores on any “step” of the examinations?
45
Section I
57.
Check here if you are a foreign institution that is not a foreign veterinary school, and go to
Section J.
Is any part of your program of Veterinary instruction provided in the United States?
Yes
No
Name of facility
Business street address
City
State and Zip +4
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address
46
Section J
Section J. Please tell us about your third-party
servicers. (This includes your Ability to
Benefit Test.)
58a.
If you contract with any third-party servicer to perform any function relating to federal student
financial aid programs, or use an ability to benefit test for students who do not have a high
school diploma or its recognized equivalent, provide the following information about each
servicer and/or tester.
Note: Do not list independent auditors. Also do not list vendors that provide books, forms, or
computer programs (in other words, do not list vendors unless they actually perform services
or functions for which you are responsible under the HEA programs).
Name of president or chief executive officer of the servicer, as indicated in your contract
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Job Title
Company name
(Please enter the company name. If there is no company name, enter the tester’s name.)
Business street address
City
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
47
Section J
E-mail address
Indicate the service provided:
Performing needs analysis
Authorizing financial aid
Disbursing financial aid
Performing loan servicing
Counseling/providing information for students
Performing loan collection
Preparing/maintaining student aid transcripts (Transfer student monitoring requirement)
Ability to Benefit Tester
Other (specify)
Check here if you need space to give more than one answer and continue on a separate sheet. On the separate sheet,
repeat the question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for
each question. Insert continuation sheets following the page where the question is asked.
58b.
Identify which ability to benefit test you use.
48
Section K
Section K. Please assure us of your administrative
capability and your financial responsibility.
Note:
To expand on any of your answers or explain why the question was not answered, use Question 69..
59.
Do you have a system of internal checks and balances for administering federal student financial
aid that meets federal regulations? (See 34 CFR 668.16.)
Yes
60.
Do you divide the functions of determining student awards and disbursing funds that result from
those award decisions? (See 34 CFR 668.16.)
Yes
61.
Do you have procedures that ensure frequent, periodic reconciliation of fiscal office and financial
aid office award data? (See 34 CFR 668.14, 668.16, 668.24, 674.19, 675.19, 676.19, and 690.81.)
Yes
62.
Do you have a system to identify and resolve discrepancies in information you receive from
various sources about a student’s application for financial aid? (See 34 CFR 668.16.)
Yes
63.
Do you have a policy that meets federal regulations for requiring satisfactory academic progress
for recipients of federal student financial aid? (See 34 CFR 668.16 and 668.34.)
Yes
64.
Do you have procedures that ensure that your requests for federal cash do not exceed the amount of
funds you need immediately to make aid disbursements to students? (See 34 CFR 668.163.)
Yes
65.
Do you have a policy that meets federal regulations for returning Title IV funds when a student
withdraws from classes? (See 34 CFR 668.22.)
Yes
49
Section K
66a.
Have you submitted your required annual financial statement audits to us on time? (For
initial applicants, have you established a process to ensure that you submit your required
annual financial statement audit to us on time?) (See 34 CFR 668.23.)
Yes
66b.
Have you submitted your required annual federal student financial aid compliance audits to us on time?
(For initial applicants, have you established a process to ensure that you submit your required annual
federal student financial aid compliance audit to us on time?) (See 34 CFR 668.23.)
Yes
67.
Do you use the electronic processes required by the Secretary? (See 34 CF668.16)
Yes
68.
Do you have a process to insure you obtain the necessary approvals from the Department for expanding or
re-establishing your institutional eligibility, (such as changes of ownership resulting in a change of control,
excluded changes in ownership, or adding new locations in certain circumstances), and that you notify us
within 10 days about other important changes (such as changing your name, address or official)? (See 34
CFR 600.10, 600.20 and 600.21)
Yes
69.
(Optional) Use this area to provide your emergency contact information, tell us about any unusual
circumstances, or provide additional explanations about your application.
Check here if you need additional space and continue on a separate sheet. On the separate sheet, repeat the
question being answered, numbering each sheet as page 1 of 3, page 2 of 3, and so on as appropriate for each
question. Insert continuation sheets following the page where the question is asked.
50
Section K
70 a.
(Optional) Provide the following information for any person or firm outside your institution that you
wish to designate as your agent to represent you in matters related to this application.
First name, Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Job Title
Company name
Business street address
City
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address
70 b.
Provide the following information for your institution's destination point administrator (DPA). First name,
Middle initial, Last name
(include prefix, such as Mr., Ms., Dr.)
Job Title
Company Name
51
Section K
Business street address
City
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
ext:
E-mail address
71.
Reporting of Foreign Gifts, Contracts and Relationships.
Note: All domestic institutions that receive any Federal financial assistance (directly or indirectly) and
offer a bachelor's degree or higher or that offer a transfer program of not less than two years that is
acceptable for credit toward a bachelor's degree are required to report foreign gifts, contracts, or ownership
and control. This information must be reported to the Secretary no later than January 31 or July 31,
immediately following receipt of gifts from a foreign source or contracts with a foreign entity that exceed
$250,000 in any calendar year, and any ownership interest in or control over the institution by a foreign
entity. (Please provide a description of any conditions or restrictions associated with the foreign gift in
Question 69.)
Gift Type
Date received
(mm/dd/yyyy format)
Amount
52
Section K
Giver Name
Country
Contract Start Date
(mm/dd/yyyy format)
Contract End Date
(mm/dd/yyyy format)
53
Section L
Section L. Please have the appropriate person in
authority review, sign, and date this document.
I hereby certify that, to the best of my knowledge and belief, all information in this document is true and
correct. I understand that if my institution provides false or misleading information, (a) the U.S. Department
of Education may deny the institution’s request for eligibility to participate in federal student financial aid
programs and/or revoke eligibility once it has been granted and (b) the institution may be liable for all federal
student financial aid funds it or its students received. I also understand that I may be subject to a fine of not
more than $58,328 or imprisonment of not more than five years, or both, for misinformation that is material
to receipt and stewardship of federal student financial aid funds.
Signature of President/CEO/Chancellor
Date
Name of institution
Name of President/CEO/Chancellor
Check here if this is the same person as in Question 10. If not, complete the information below.
Job Title
Business street address
City
State and Zip+4 (or Foreign Province, Postal Code, and Country, if outside the U.S.)
Telephone number (including area code)
ext:
Fax number (including area code)
54
ext:
E-mail address
55
Section M
Section M. Please include copies of appropriate
documents as part of your application.
Indicate all copies of documents you are including with this application.
Current letter of accreditation and any attachments. (See Question 15)
(Please Note: The accreditation certificate is not sufficient documentation)
Valid state license or other state authorization (See Question 17)
For private nonprofit institutions-501(c)(3) designation from the IRS (See Question 18)
If your institution contracts with an organization or ineligible institution to provide more than 25%
of any educational program-a copy of the approval from your accrediting agency for contracting
this program (See Question 28)
For initial applicants (See Question 35)
Audited financial statements for the (two) most recently completed fiscal year(s)
Default management plan: Either
The default management plan recommended by the Secretary of
Education. (check this box, do not include the plan); or
A default management plan other than the plan recommended by the Secretary of
Education. (enclose a copy of the plan); or
The institution is exempt under 487(a)(14)(C) of the HEA from
providing a default management plan.
For institutions with a change in ownership or structure (See Question 35)
Audited financial statements of the institution's two most recently completed fiscal years that are
prepared in accordance with Generally Accepted Accounting Principles (GAAP) and audited in
accordance with Generally Accepted Government Auditing Standards (GAGAS); and
Audited financial statements of the institution's new owner's two most recently completed fiscal years
that are prepared in accordance with Generally Accepted Accounting Principles (GAAP) and audited
in accordance with Generally Accepted Government Auditing Standards (GAGAS) or equivalent
information for that owner that is acceptable to the Secretary.
Same-day balance sheet, audited in accordance with GAGAS, showing the financial condition
of the institution after the change in ownership.
56
Section M
Default management plan: Either
The default management plan recommended by the Secretary of
Education. (check this box, do not include the plan); or
A default management plan other than the plan recommended by the Secretary of
Education. (enclose a copy of the plan); or
The institution is exempt under 487(a)(14)(C) of the HEA from providing a
default management plan.
For institutions seeking reinstatement (See Question 35)
Audited financial statements for the two most recently completed fiscal years that are prepared
in accordance with Generally Accepted Accounting Principles (GAAP) and audited in
accordance with Generally Accepted Government Auditing Standards (GAGAS).
Default management plan: Either
The default management plan recommended by the Secretary of
Education. (check this box, do not include the plan); or
A default management plan other than recommended by the Secretary of
Education. (enclose a copy of the plan); or
The institution is exempt under 487(a)(14)(C) of the HEA from providing
a default management plan.
For foreign institutions, including foreign graduate medical schools
For private nonprofit institutions-a certified English translation of nonprofit designation status
(See Question 18)
Most recent catalog and its certified English translation of all sections dealing with
degrees and programs provided at your institution (See Section I)
Legal authorization and its certified English translation to provide an educational program
beyond the secondary school level in the country where you are located (See Question 42)
Legal authorization and its certified English translation to award a degree that is equivalent to
a degree awarded in the United States (See Question 43)
57
Section M
Legal authorization and its certified English translation to provide graduate medical,
education (See Question 49)
In addition, if a foreign institution is an initial applicant
Audited financial statements for the two most recent years
Default management plan: Either
The default management plan recommended by the Secretary of Education. (check this
box, do not include the plan); or
A default management plan other than the plan recommended by the Secretary of
Education. (enclose a copy of the plan); or
The institution is exempt under 487(a)(14)(C) of the HEA from providing
a default management plan.
For institutions applying for Comprehensive Transition and Postsecondary Programs (See Question 26k)
A detailed description of your comprehensive transition and postsecondary program addressing all
of the components of the program as defined in 34 C.F.R 668.231
A copy of your institution's Satisfactory Academic Progress policy for the comprehensive
transition and postsecondary program
A copy of the notification to your primary accreditor that your institution is providing a
comprehensive transition and postsecondary program
58
| File Type | application/pdf |
| Author | Authorised User |
| File Modified | 2022-08-01 |
| File Created | 2019-07-05 |