USAREC Form 601-37.12 "Certificate of Enrollment for the US Army Health Professions Scholarship Program"

USAREC Form 601-37.12 or the "Certificate Of Enrollment For The Us Army Health Professions Scholarship Program" is a form issued by the United States Army Recruiting Command.

Download a PDF version of the USAREC Form 601-37.12 down below or find it on the United States Army Recruiting Command Forms website.

ADVERTISEMENT

Download USAREC Form 601-37.12 "Certificate of Enrollment for the US Army Health Professions Scholarship Program"

694 times
Rate
(4.6 / 5) 35 votes
CERTIFICATE OF ENROLLMENT FOR THE US ARMY HEALTH PROFESSIONS SCHOLARSHIP PROGRAM
(For use of this form see USAREC Reg 601-37)
PRIVACY ACT STATEMENT
AUTHORITY: 10 USC 3012; 10 USC 4301; Executive Order 9397.
PRINCIPAL PURPOSE: To document and certify student enrollment and graduation data.
ROUTINE USES: The Enrollment Certificate will be used to verify status and authorize payment of scholarship entitlements. Information is used for
identification purposes.
MANDATORY OR VOLUNTARY DISCLOSURE: Voluntary. If not submitted, scholarship entitlement information is considered incomplete and will
not be processed.
SECTION I - TO BE COMPLETED BY HEALTH CARE RECRUITER
(Please type entries)
1. TO
:
2. FROM
:
(Name and address of school)
(Recruiting office and address)
3. The below named individual has been accepted to participate in the U.S. Army Health Professions Scholarship Program (HPSP). Please complete
Section II or Section III, as appropriate, and return this form to the above office in the enclosed self-addressed envelope. Prompt response will be
appreciated as we cannot process the student's financial records without this completed form.
5. CURRENT ADDRESS OF STUDENT:
4. NAME OF STUDENT:
6. NAME AND TITLE OF REQUESTER:
7. SIGNATURE AND TELEPHONE NUMBER OF REQUESTER:
SECTION II - ENROLLED STUDENTS
(To be completed by Dean of Student Affairs or Registrar)
8. IS STUDENT CURRENTLY ENROLLED IN A FULL TIME STATUS AND IN
9. DATE CLASSES IN NEXT ACADEMIC YEAR TO BEGIN
(Month,
GOOD STANDING:
:
day, year)
YES
NO
SECTION III - INDIVIDUALS ACCEPTED FOR ENROLLMENT
(To be completed by Dean of Student Affairs or Registrar)
(The entry in Item 11 excludes registration or orientation, unless all are the same day.)
10. DATE OR DATES OF ORIENTATION
(Month, day, year):
11. DATE CLASSES IN NEXT ACADEMIC YEAR TO BEGIN
(Month, day, year):
12. DATE NEXT ACADEMIC YEAR ENDS
:
(Month, day, year)
SECTION IV - DEGREE PURSUED
20. ROTC COOP PHARMACY
13. MEDICAL
21. ENROLLMENT STATUS:
14. OSTEOPATHY
Resident
Nonresident
15. DENTAL
16. OPTOMETRY
22. ESTIMATED COST OF ANNUAL TUITION AND FEES:
Resident
Nonresident
17. CLINICAL or COUNSELING PSYCHOLOGY
18. NURSE ANESTHESIA, PSYCHIATRIC NURSE PRACTITIONER
23. PROJECTED GRADUATION DATE (Required):
NURSE MIDWIFERY OR FAMILY NURSE PRACTITIONER
19. VETERINARY MED
24. I certify that the student named above is enrolled (or accepted for enrollment) in this institution for the purpose of pursuing the graduate degree
indicated and that by pursuing this course of study the student does not incur any medical practice obligations other than that which may be required
by the United States Army.
25. DATE:
26. NAME AND TELEPHONE NUMBER OF DEAN:
27. SIGNATURE AND TITLE OF VERIFYING OFFICIAL:
USAREC Form 601-37.12 (update), JUL 18
V4.00
CERTIFICATE OF ENROLLMENT FOR THE US ARMY HEALTH PROFESSIONS SCHOLARSHIP PROGRAM
(For use of this form see USAREC Reg 601-37)
PRIVACY ACT STATEMENT
AUTHORITY: 10 USC 3012; 10 USC 4301; Executive Order 9397.
PRINCIPAL PURPOSE: To document and certify student enrollment and graduation data.
ROUTINE USES: The Enrollment Certificate will be used to verify status and authorize payment of scholarship entitlements. Information is used for
identification purposes.
MANDATORY OR VOLUNTARY DISCLOSURE: Voluntary. If not submitted, scholarship entitlement information is considered incomplete and will
not be processed.
SECTION I - TO BE COMPLETED BY HEALTH CARE RECRUITER
(Please type entries)
1. TO
:
2. FROM
:
(Name and address of school)
(Recruiting office and address)
3. The below named individual has been accepted to participate in the U.S. Army Health Professions Scholarship Program (HPSP). Please complete
Section II or Section III, as appropriate, and return this form to the above office in the enclosed self-addressed envelope. Prompt response will be
appreciated as we cannot process the student's financial records without this completed form.
5. CURRENT ADDRESS OF STUDENT:
4. NAME OF STUDENT:
6. NAME AND TITLE OF REQUESTER:
7. SIGNATURE AND TELEPHONE NUMBER OF REQUESTER:
SECTION II - ENROLLED STUDENTS
(To be completed by Dean of Student Affairs or Registrar)
8. IS STUDENT CURRENTLY ENROLLED IN A FULL TIME STATUS AND IN
9. DATE CLASSES IN NEXT ACADEMIC YEAR TO BEGIN
(Month,
GOOD STANDING:
:
day, year)
YES
NO
SECTION III - INDIVIDUALS ACCEPTED FOR ENROLLMENT
(To be completed by Dean of Student Affairs or Registrar)
(The entry in Item 11 excludes registration or orientation, unless all are the same day.)
10. DATE OR DATES OF ORIENTATION
(Month, day, year):
11. DATE CLASSES IN NEXT ACADEMIC YEAR TO BEGIN
(Month, day, year):
12. DATE NEXT ACADEMIC YEAR ENDS
:
(Month, day, year)
SECTION IV - DEGREE PURSUED
20. ROTC COOP PHARMACY
13. MEDICAL
21. ENROLLMENT STATUS:
14. OSTEOPATHY
Resident
Nonresident
15. DENTAL
16. OPTOMETRY
22. ESTIMATED COST OF ANNUAL TUITION AND FEES:
Resident
Nonresident
17. CLINICAL or COUNSELING PSYCHOLOGY
18. NURSE ANESTHESIA, PSYCHIATRIC NURSE PRACTITIONER
23. PROJECTED GRADUATION DATE (Required):
NURSE MIDWIFERY OR FAMILY NURSE PRACTITIONER
19. VETERINARY MED
24. I certify that the student named above is enrolled (or accepted for enrollment) in this institution for the purpose of pursuing the graduate degree
indicated and that by pursuing this course of study the student does not incur any medical practice obligations other than that which may be required
by the United States Army.
25. DATE:
26. NAME AND TELEPHONE NUMBER OF DEAN:
27. SIGNATURE AND TITLE OF VERIFYING OFFICIAL:
USAREC Form 601-37.12 (update), JUL 18
V4.00
ADVERTISEMENT