Fillable Printable VA Form 10-0491
Fillable Printable VA Form 10-0491
VA Form 10-0491
1. Applicant must sign and date the "Consent for Release of Information."
2. This "Academic Verification" form is part of the application package and must be completed by the Dean/Program Director, or Administrative Chair
of applicant's program.
3. The applicant is responsible for ensuring that all documents are returned to the scholarship program office by the due date.
4. Submit completed documents to:
HPSP/VIOMPSP
Department of Veterans Affairs
1250 Poydras Street, Suite 1000
New Orleans, LA 70113
13. Expected date that academic requirement(s), including all clinical rotations and/or projects will be completed:
1. Name (Last, First, MI):
2. SSN:
3. Name of college or university where applicant is enrolled/accepted (Do Not Abbreviate):
Other
DoctorateMaster'sBaccalaureateAssociate
5. Clinical Program:
4. Degree sought with this scholarship
(Check one only)(VIOMPSP must be Baccalaureate or higher):
(Specify)
6. Please list the specific degree and specialty:
8. Applicant enrollment status (check one).
To be eligible for the scholarship award, the student must be
unconditionally admitted to the program and degree level by the
time the awards are granted. Therefore, it is critical that an
"Addendum to Application" form is submitted by the school if the
admission status changes.
Probational admission (Please explain)
Conditional/Pending admission (Please explain, including anticipated date of
meeting requirements for unconditional admission)
Unconditionally admitted
OMB Number: 2900-0793
Estimated Burden: 60 minutes
Information from Applicant
Consent for Release of Information
CONSENT: I authorize the educational institution in which I am, or will be, enrolled to release to VA information regarding my enrollment status and
academic standing, including grade point average, both now and while I am participating in the VA Health Professional Scholarship Program/Visual
Impairment and Orientation and Mobility Professionals Scholarship Program as well as the plan of study and projected costs. I understand that this
authorization is voluntary, and that I may revoke this consent at any time. However, I further understand that if I voluntarily revoke this authorization
after the award of the scholarship, my scholarship award may be terminated and I may be liable for the damages in accordance with provisions of
38 U.S.C. Sections 7505 and 7617.
Accreditation of Academic Program
Admission, Enrollment and Program Completion Information
8a. Explanation:
7. Name of the organization that accredited your academic program:
Applicant's Signature
Date Signed
Accreditation expiration date:
Academic Verification
Health Professional Scholarship Program (HPSP) &
Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
Part-timeFull-time
Quarter Semester
10. Will the applicant be attending full-time or part-time? (HPSP must be full-time)
12. Date that classes begin for the
upcoming fall semester/quarter:
9. What is full-time enrollment at your university/college?
Credit Hours per
14. Expected date degree will be conferred:
VIOMPSPHPSP
If program is not accredited, the applicant is not eligible for the scholarship program and this form does not need to be completed.
Representative from the program should explain the lack of accreditation to the applicant.
PAGE 1 of 5
11. Date the applicant started or will start your
program under this scholarship program:
10-0491
VA FORM
DEC 2013
QuarterSemester
Semester Quarter
Cumulative Grade Point Average (CGPA)
For Graduate Students
Undergraduate Cumulative Grade Point Average (CGPA) need not be identified if the student has completed 15 or more graduate hours and is
pursuing a graduate degree. If the student has not achieved 15 hours of graduate credit, identify CGPA and credit hours for all undergraduate
hours and if applicable, CGPA on credit hours for all graduate academic courses completed.
For Undergraduate Students
CGPA must be computed on all post-secondary academic courses taken within past 10 years. It should not be computed only on academic
courses accepted as satisfying the requirements of the degree for which the applicant is requesting a scholarship.
If the applicant completed academic courses more than 10 years ago, CGPA should be computed on all courses used for admission to the
program for which the scholarship is being requested.
Undergraduate CGPA
Graduate CGPA
credit hours
based on
based on
credit hours
**If there is a change in the CGPA status
after submission of this document,
forward the ADDENDUM to the
Scholarship Program immediately.
16.
15.
Plan of Study and Projected Costs
17. For each term please list:
HPSP/VIOMPSP Academic Verification (continued)
Course Number
Course Title
Credit Hrs
Tuition
Total CH
Fees
Cost
Total Projected Cost
for Semester
List allowable fees for this term or that start during this term if they continue into the next term.
Start Date End Date
Total Fees
Total Tuition
Applicant Name:
- Course number and title - Total credit hours for the term
- Credit hours for each course - Projected tuition cost
Allowable Fees:
(*Do not include books, supplies and equipment.)
- Required fees for approved curriculum such as laboratory expenses
- Matriculation fees
- Graduation fees
- Library fees
- Malpractice insurance (if required for all students in the same academic program)
Non-allowable Fees: - Books - Health/medical/dental/vision/life insurance
- Computers and software - Study abroad fees
- Late charges - Travel costs for clinical rotations
- Parking fees - Membership dues for student societies, associations and similar expenses
- Licensure/Certification Courses/Reviews
(Annual lump-sum "Other Related Costs" payments may be used to pay for these items.)
Notes: - Tuition and fees will not be paid for courses that are being repeated.
- Specifically identify fees and whether required or optional.
Semester/Quarter
PAGE 2 of 5
10-0491
VA FORM
DEC 2013
Course Number
Course Title
Credit Hrs
Tuition
Fees
Cost
List allowable fees for this term or that start during this term if they continue into the next term.
Start Date End Date
Start Date End Date
HPSP/VIOMPSP Academic Verification (continued)
Course Number
Course Title Credit Hrs Tuition
Fees Cost
List allowable fees for this term or that start during this term if they continue into the next term.
Start Date End Date
Course Number
Course Title Credit Hrs
Tuition
Fees
Cost
List allowable fees for this term or that start during this term if they continue into the next term.
Applicant Name:
Total CH
Total Projected Cost
for Semester
Total Fees
Total Tuition
Total CH
Total Projected Cost
for Semester
Total Fees
Total Tuition
Total CH
Total Projected Cost
for Semester
Total Fees
Total Tuition
Semester/Quarter
Semester/Quarter
Semester/Quarter
PAGE 3 of 5
10-0491
VA FORM
DEC 2013
HPSP/VIOMPSP Academic Verification (continued)
Start Date End Date
Course Number
Course Title
Credit Hrs Tuition
Fees Cost
List allowable fees for this term or that start during this term if they continue into the next term.
Start Date End Date
Course Number Course Title
Credit Hrs
Tuition
Fees
Cost
List allowable fees for this term or that start during this term if they continue into the next term.
Start Date End Date
Course Number
Course Title Credit Hrs
Tuition
Fees
Cost
List allowable fees for this term or that start during this term if they continue into the next term.
Applicant Name:
Total CH
Total Projected Cost
for Semester
Total Fees
Total Tuition
Total CH
Total Projected Cost
for Semester
Total Fees
Total Tuition
Total CH
Total Projected Cost
for Semester
Total Fees
Total Tuition
Semester/Quarter
Semester/Quarter
Semester/Quarter
PAGE 4 of 5
10-0491
VA FORM
DEC 2013
Start Date End Date
Course Number Course Title Credit Hrs
Tuition
Fees
Cost
List allowable fees for this term or that start during this term if they continue into the next term.
Start Date End Date
Course Number Course Title
Credit Hrs Tuition
Fees Cost
List allowable fees for this term or that start during this term if they continue into the next term.
Phone Number (include area code) E-mail Address
Signature (Dean/Program Director/Administrative Chair of Program)
Name (Print)
Date
I understand it is my responsibility to notify the scholarship program if there are any changes in CGPA, admission status, enrollment status, plan of study,
projected costs, or program accreditation. I certify the accuracy of all information stated on this Form.
Title
Certification
Please enclose a copy of the school's academic program curriculum.
HPSP/VIOMPSP Academic Verification (continued) Applicant Name:
Total CH
Total Projected Cost
for Semester
Total Fees
Total Tuition
Total CH
Total Projected Cost
for Semester
Total Fees
Total Tuition
Semester/Quarter
Semester/Quarter
PAGE 5 of 5
(Forward the ADDENDUM to the Scholarship Program immediately. Inaccurate data may cause both the school and the student to lose funding.)
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.
10-0491
VA FORM
DEC 2013
