Fillable Printable VA Form 10-0491g
Fillable Printable VA Form 10-0491g
VA Form 10-0491g
INSTRUCTIONS: Please furnish all information in sufficient detail to enable the Department of Veterans Affairs (VA) to determine your eligibility and
ranking for selection to receive a scholarship from VA. Type or print in ink. If additional space is required, use the space in Section V.
The following items constitute a complete application package.
It is your responsibility to ensure that your application package is complete, accurate, and submitted by the deadline date.
Incomplete applications will not be reviewed.
5. Are you a citizen of the United States?
1. Are you currently enrolled or have you been accepted for full-time or part-time enrollment in an academic program that will
qualify you for employment in one of the fields and educational level listed in the program materials for this application cycle?
The academic program must be located in the United States.
2. Do you have a cumulative grade point average of 3.0 or above if some coursework is already completed?
3. FOR HPSP ONLY. Are you able to perform a clinical tour in an assignment or location determined by VA while enrolled in
the course of education for which the scholarship is provided? This will require temporary relocation at your expense if there is
not a VA facility near your educational program or if your education program does not have an affiliation agreement with the
nearby VA facility. Check with your advisor before answering this question.
6. Are you delinquent on payment of a federal debt? This includes delinquent taxes, audit disallowances, guaranteed or direct
student loans, Federal Housing Administration (FHA) or VA mortgages, and other miscellaneous administrative debts.
Delinquent is defined as 31 days past due on a scheduled payment.
4. Are you able to complete the required full-time VA employment obligation after graduation and required licensure/
certification? This will require relocation at your expense if there is not a suitable vacancy or you are not selected for
employment at a VA facility nearby.
7. Do you currently owe a service obligation to any other entity to perform service after you complete the course of study for
which this scholarship is being provided?
If you answered "No" to any of questions 1-5
or
answered "Yes" to questions 6 or 7,
you are NOT eligible for this scholarship program and you should not submit an application.
PRELIMINARY ELIGIBILITY QUESTIONS
Yes No
SUMMARY OF THE COMPLETE APPLICATION PACKAGE
Yes No
N/A for
VIOMPSP
Yes No
Yes No
Yes No
Yes No
Yes No
OMB Number: 2900-0793
Estimated Burden: 60 minutes
APPLICATION
Health Professional Scholarship Program (HPSP) &
Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
SEE LAST PAGE FOR PAPERWORK REDUCTION ACT, PRIVACY ACT AND INFORMATION ABOUT DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER
1. HPSP_VIOMPSP Application (VA Form 10-0491g)
2. Academic Verification Form (VA Form 10-0491)
3. Evaluation & Recommendation Forms (VA Form 10-0491e)
3a. From academic program where you will be or where you are currently enrolled (Required)
3b. From a person who has known you for a minimum of two years (Required)
3c. From your VA supervisor or equivalent person if the supervisor is no longer available
4. Academic Transcript (Unofficial transcript acceptable)
5. Resumé
6. Declaration for Federal Employment (OF 306)
(Include prior education, professional licenses/registration/certifications and detailed descriptions of volunteer and work experiences
especially that which is healthcare related. Resumés should not exceed 5 pages and must be at least 11 point font. Resumés that are
longer in length or written in smaller font will not be reviewed.)
(Required if you were employed by Department of Veterans Affairs in the last three years)
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SECTION II - Applicant Information
7a. Primary Phone Number (include area code)
7b. Alternate Phone Number (include area code)
9b. Alternate Email Address
HPSP VIOMPSP
1. Scholarship Program
11. Are you a previous HPSP/VIOMPSP recipient?
5a. Name
(Last, First, Middle) 5b. Other Names Used (For example: maiden name, nickname, etc.)
10. Are you a U.S. Citizen?
8. Social Security Number
Yes No
Yes No
6. Present Address (Include Street Address, City, State, and ZIP Code)
If yes, date you completed your obligation :
Name, permanent address, and telephone number of person through whom you can be located (e.g., parent, sibling, friend, etc...):
13. Relationship12. Name (Last, First, Middle)
SECTION I - Scholarship Program Information
3. Clinical Program:
9a. Primary Email Address
Application for Health Professional Scholarship Program (HPSP) &
Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
Baccalaureate
Associate (HPSP only)
Master's Doctorate
Other (Specify)
4. Degree sought via
HPSP/VIOMPSP
(Check one only)
Major field of study
2. Length of Award (More than 12 months of
scholarship support is considered a multi-year
award)
1 year 2 or more years
16. Email Address
15. Phone Number (include area code)
14. Address (Include Street Address, City, State, and ZIP Code)
17. Highest degree obtained
(Check only highest
completed)
NoYes
NoYes (Provide information below)
DoctorateMaster's
Associate Baccalaureate Other (Specify)
Major field of Study
18. Do you or will you have a service obligation (commitment of service) that will conflict with a service obligation incurred
under the scholarship program for which you are currently applying?
(If Yes, explain in Section V.)
19. Have you served in the military including active duty and reserves?
From To Branch of Service/Military Occupation Type of Discharge
Honorable Other (Explain in Section V)
Honorable Other (Explain in Section V)
Honorable Other (Explain in Section V)
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SECTION III - Education Program Information
27b. Advisor's Phone Number
a. Traditional (On campus) programs
consisting of curricula offered in
a campus setting.
b. Non-Traditional (Off campus) programs consisting
of curricula in off-campus settings (e.g., distance
learning via the internet).
c. Mixed Traditional
and Non-Traditional
28. Type Program
25. Phone Number (include area code)
26. Address (Include Street Address, City, State, and ZIP Code)
23. Name of college or university where you are enrolled/accepted. (Do Not Abbreviate)
24. Name of college/department/school
29. Start date of academic program that will
be supported by the scholarship program
Yes No
31. NOTE: The HPSP requires that scholarship participants perform clinical tours in assignments or locations determined by VA while enrolled in the
course of education for which the scholarship is provided. This may require temporary relocation at your expense if there is not a VA facility near
your educational program, or if your education program does not have an affiliation agreement with the VA facility nearest you. Check with your
advisor before answering this question. The VIOMPSP does not require clinical tours.
27a. Academic Advisor
27c. Advisor's Email
20. Were you ever convicted by a court-martial?
(If so, describe in Section V.) Yes No
Application for HPSP/VIOMPSP (continued)
21a. Are you a current or previous Department of Veterans Affairs employee?
No
Yes
Current PreviousNo
21e. Occupational Series Code 21f. Job Title
21b. If VA employed, Start Date of last VA employment 21c. End Date of last VA employment
22. Have you ever been employed in a healthcare occupation?
(If not described in Resumé,
describe in Section V.)
Described in Resumé
Described in Section V
30. End date of academic program that will be
supported by the scholarship program
Are you willing and able to meet this scholarship program requirement?
SECTION IV - Additional Applicant Information
32. Awards (academic/performance):
33. Professional Activities:
21d. Location
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34. Organizational Membership(s)/Office(s) Held:
35a. Why do you want to participate in the scholarship program for which you are applying? (250 word limit)
35b. What are your short-range (less than five years) and long-range (between five and ten years) career goals? (250 word limit)
Please respond to the questions 35A-C within the space provided. (Use only 10pt or 12pt font) (250 word limit per section)
Application for HPSP/VIOMPSP (continued)
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40. Have you ever been convicted, forfeited collateral, or are you now under charges for any felony or any firearms or explosives
offense against the law? (A felony is defined as any offense punishable by imprisonment for a term exceeding one year, but does
not include any offense classified as a misdemeanor under the laws of a State and punishable by a term of imprisonment of two
years of less.) (If yes, please explain in Section V.)
NoYesa. Professional Registration/License in any State?
35c. How will your personal characteristics, experiences and career goals help meet the health needs of Veterans? (250 word limit)
Application for HPSP/VIOMPSP (continued)
36. Have any of the following ever been, or are they in the process of being -- either on a voluntary or involuntary basis -- denied, revoked, suspended,
reduced, limited, placed on probation, not renewed, withdrawn, or relinquished while under investigation or for disciplinary reasons? (Each "yes"
response requires a complete explanation in Section V.)
b. Participation in Medicare/Medicaid Program, or been convicted of and or investigated for making and or using false,
fictitious, or fraudulent statements, representations, writings or documents, regarding a material fact in connection with the
delivery of, or payment for health care benefits, items or services that would be in violation of the Criminal False Claims
Act?
c. Clinical Privileges?
Yes No
Yes No
Yes No
Yes No
d. Federal Drug Enforcement Agency Registration?
e. Certification?
39. Within the last 5 years have you resigned or retired from a position after being notified you would be disciplined or discharged, or
after questions about your clinical competence were raised? (If yes, please explain in Section V.)
37. Have you ever been involved in administrative, or judicial proceedings in which professional malpractice on your part has been
alleged? (If yes, please explain in Section V.)
38. Within the last 5 years, have you been discharged from any position for any reason? (If yes, please explain in Section V.)
NoYes
NoYes
NoYes
Yes No
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b. I am aware of the required service obligation to work in a VA health care facility in a full-time position for which I will be
prepared after completing the education program supported by the scholarship program. This will require relocation at my
expense if there is not a suitable vacancy or if I am not selected for employment at a nearby VA facility.
a. FOR HPSP ONLY. I am aware of the required clinical tour in an assignment or location determined by VA while enrolled
in the course of education for which the scholarship is provided. This will require relocation at my expense if there is not a
suitable VA facility near my educational program or if my education program does not have an affiliation agreement with the
nearby VA facility.
c. I am aware of the penalties as described in the scholarship agreement if I do not complete the education program for which I
am requesting scholarship support or if I do not complete the required service obligation.
Application for HPSP/VIOMPSP (continued)
41. Are you delinquent on the repayment of any Federal debt(s)? If yes, please explain in the Section V. (Examples of Federal Debt
include delinquent taxes, audit disallowances, guaranteed or direct student loans, FHA loans, and other miscellaneous
administrative debts. The definition of delinquency for the purposes of direct and guaranteed loans are any loan(s) more than 31
days past due on a scheduled payment. Deferred loans are not considered delinquent.)
Yes No
42. Scholarship Program Requirements:
SECTION V - Supplemental Information
43. Enter explanations to prior questions and supplemental information. (Be sure to indicate the corresponding question number on the form to which the
comment refers.)
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SECTION VI - Authentication
I certify that the information given in this application is accurate and complete to the best of my knowledge and belief. I understand that any information I
have provided may be investigated and that any false representation is sufficient cause for rejection of this application or, if granted and award, that I am
liable for repayment of all awarded funds and, further, that any false statement herein may be punishable under U.S. Code, Title 18, Section 1001. I
understand that decisions on awards will be final.
Applicant's Name (Print)
Applicant's Signature
Date
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 your
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 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
process your request for a scholarship. If you give VA your social security number, VA will use it to obtain information relevant to determining whether
to grant a scholarship, and to administer your scholarship, if awarded. It also may be used for other purposes authorized or required by law.
Submit completed application to:
HPSP/VIOMPSP
Department of Veterans Affairs
1250 Poydras Street, Suite 1000
New Orleans, LA 70113
43. Supplemental information (continued)
Application for HPSP/VIOMPSP (continued)
All material submitted becomes the property of the Federal Government and will not be returned.
Read the accompanying Applicant Information Bulletin before completing this form.
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