Fillable Printable Application Checklist
Fillable Printable Application Checklist
Application Checklist
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
INDIAN HEALTH SERVICE
PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM
APPLICATION CHECKLIST
FORM APPROVED:
OMB Approval No: 0917-0006
Exp. Date: 08/31/2013
See Estimated Average Burden Time
per Response on Reverse Side.
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 SOCIAL SECURITY NUMBER
DEGREE TRACK IHS AREA OFFICE EMAIL ADDRESS
HAVE YOU EVER RECEIVED AN IHS SCHOLARSHIP OR GRANT? Yes No
If “Yes”, enter below:
DEGREE TRACK
WHAT ACADEMIC YEAR ARE YOU APPLYING FOR? 20 – 20
I AM APPLYING FOR:
Preparatory Scholarship Program Pre-Graduate Scholarship Program Health Professions Scholarship Program
REQUIRED FORMS: Online Option Print Option
1. Application Checklist (IHS-856-2)
2. Application Bubble Sheet (IHS-856) Submitted Online
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. Federal Income Tax Withholding (Form W-4)
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. Letter of Acceptance from a College/University or
Proof of Application to a Health or Allied Health Professions Program
11. Official 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. Curriculum for Major
Attach this documentation with your Course Curriculum Verification form.
13. Complete 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 DATE
IHS-856-2 EF
