Fillable Printable VA Form 10-0491H

VA Form 10-0491H

Health Professional Scholarship Program (HPSP) &

Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)

Notice of Approaching Graduation

Submit this completed form to the Scholarship Program Office 6 months prior to graduation.

OMB Number: 2900-0793

Estimated Burden: 10 minutes

Student's Name (Last, First, Middle):

Social Security Number:

HPSP/VIOMPSP

Department of Veterans Affairs

1250 Poydras St., Suite 1000

New Orleans, LA 70113

VIOMPSPHPSP

Signature Date

Email Address:

Clinical Program: Type of Degree:

Scheduled

graduation date:

I intend to request a deferment of my service obligation in order to complete advanced clinical education.

I intend to begin my service obligation within 90 days after the educational and/or certification qualifications are met and I have

been accepted for an employment position. I do not intend to request a deferment of my service obligation.

Date all graduation

requirements will be met:

I verify the student's graduation information is accurate.

Academic Advisor Signature

I have not yet submitted applications for employment at VA facilities for my service obligation.

I have been selected by a VA facility for my service obligation.

I have submitted applications for employment at VA facilities for my service obligation.

I intend to submit my applications for employment no later than

(Submit the Status Report on Service Obligation Placement form along with this Notification of Approaching Graduation.)

(Please send a copy of your Optional Application for Federal Employment (OF 612) or a copy of the position application)

PAGE 1 of 1

Date

Please check applicable boxes:

(Please send a copy of your Optional Application for Federal Employment (OF 612) or a copy of the position application)

(Submit the Request for Deferment form along with this Notification of Impending Graduation.)

(Please send a copy of your Optional Application for Federal Employment (OF 612) or a copy of the position application)

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 administer your 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 continue your scholarship award. If you give VA your social security number, VA will use it to obtain

information relevant to administering your scholarship award. It also may be used for other purposes authorized or required by law.

10-0491H

DEC 2013

VA FORM