Step 1 of 8 12% HPEP Applicant QuestionaireWhich professional field are you applying for(Required) (Beginning 2023-2024)If you are applying for the RN to BSN stipend, do you plan, after earning your BSN, to pursue an Advanced Practice Registered Nursing (APRN) degree?(Required) Yes No I am not applying for RN to BSN stipend Define your program specialty(Required) Nurse Educator Family Nurse Practitioner Gerontology Psychiatric Mental Health Licensed Social Worker Other How did you hear about the Nevada Office of WICHE HPEP? Academic Advisor Website Friend Relative Employer Practitioner Other Personal InformationName(Required) First Middle Last Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Birthplace(Required) (City/State)Date of Birth(Required) Educational InformationHigh School(Required) Location(Required) (City/State)Year Graduated College(Required) Location(Required) (City/State)Year Graduated Are you currently enrolled or admitted in a professional program?(Required) Yes No Name of the school where you are currently enrollled Field of Study Semester Started (Month and year you started your currently active program)Enrollment Type Full Time Part Time Certificate Estimated Graduation Date (Month and year of your estimated graduation date) School PreferenceList, in order of preference, the professional schools to which you are applying. Make sure to attach your professional school acceptance letter before submitting application.First ChoiceName of School City/State City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Have you been accepted? Yes No Second ChoiceName of School City/State City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Have you been accepted? Yes No Employment HistoryEmployer Name(Required) Job Title(Required) Employer Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Length of Employment(Required) (Years / Months)Is your employer also contributing funding towards the cost of your education?(Required) Yes No Amount contributed by employer, per year Nevada Residency InformationTo qualify for residency, you must have been a bona fide resident of Nevada for at least 12 consecutive months prior to submitting your HPEP application. You will be required to provide proof documenting Nevada residency such as a copy of your Nevada driver’s license. Additional documents may be requested to verify Nevada residency.Are you a United States citizen or permanent resident?(Required) Yes No Are you a legal resident of Nevada?(Required) Yes No State of legal residenceAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStart date of current residence(Required) (mm/yyyy)End date of current residence(Required) (mm/yyyy)Driver's License No. Date Issued (MM/YYYY)State of IssueAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCounty of Legal Residence Start date of residence in this county (MM/YYYY) Please Upload Supporting DocumentsLetter of acceptance from your professional program(Required)To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your files Format: PDF • JPG • JPEG • PNGMaximum size: 256 MB Files Nevada Driver's License(Required)To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your files Format: PDF • JPG • JPEG • PNGMaximum size: 256 MB Files Please upload a photo of your valid Nevada Driver’s license for verification of residenceAre you are currently enrolled in your professional program?(Required) Yes No Unofficial TranscriptTo view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your files Format: PDF • JPG • JPEG • PNGMaximum size: 256 MB Files Please upload your unofficial transcript Final StepApplication Certification & Statement of Intent To Provide Service(Required) I understand and agree to the following:Upon fulfillment of my professional studies, I will return, obtain my practice license (nursing or social work), and practice my profession (employment) in an underserved medical or health professional shortage area in the State of Nevada.Acknowledgement of Practice Duration in Nevada(Required) I understand and agree to the following:I will provide one (1) year of full-time practice in my profession for each year of Nevada HPEP stipend received.Acknowledgement of Intent to complete practice questionnaire(Required) I understand and agree to the following:I will notify the Nevada Office of WICHE of any changes related to my contact information and complete a Practice Questionnaire twice a year (fall/spring) with supporting documentation during school and out of school to demonstrate compliance with HPEP requirements.Acknowledgement of understanding for stipend requirements(Required) I understand and agree to the following:I further understand that if I do not complete my employment obligation, or do not complete my course of study the stipend amount I received will be converted to a loan, with interest, fees, and any applicable penaltiesAcknowledgement of understanding for funding limitations(Required) I understand and agree to the following:I understand that continuation of Nevada HPEP funding is subject to legislative appropriation and funding limitations; therefore, support may not be guaranteed annually.Acknowledgement of public release(Required) I understand and agree to the following:I agree to allow the State of Nevada to release my name, address, and school to allow the State of Nevada to use my name in publicizing the WICHE PSEP. The State may use information about my participation for internal or public reports, research studies, or statistical analysis on program effectiveness.Acknowledgement of consent for educational record transfer(Required) I understand and agree to the following:I hereby consent to the transfer of personally identifiable educational records between and among the employees in the Nevada Office of Western Interstate Commission (WICHE) for Higher Education, Nevada WICHE Commissioners, Nevada WICHE Commissioner Appointed Applicant Reviewers, Nevada System of Higher Education System Administration employees supporting Nevada Office of WICHE programs and receiving school employees as required to carry out their official duties to include the following: Information concerning student eligibility, acceptance, and educational attainment; Information concerning fees paid by Nevada Office of WICHE to the receiving school; Lists of applicants certified as eligible for support; Admissions reports, withdrawal reports, and annual reports for Health Profession Education Program (HPEP) Students; Support agreement forms and invoices; and Special letters of inquiry and response as required to address questions and concerns identified by employees. E-Signature Acknowledgement(Required) I Agree to sign this application electronicallyBy selecting the “I AGREE” button, you acknowledge that you have read, understand and agree to the following: You are voluntarily choosing to sign your HPEP Application electronically You understand and agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and The Nevada Office of WICHE You understand that you have the right to withhold your consent to the use of electronic documents and signatures and that you have the right to withdraw your consent at any time prior to completing the e-sign process. Please be aware, however, that withdrawal of consent may result in the termination of your HPEP application. Signature(Required)HiddenSignature Date MM slash DD slash YYYY
