Step 1 of 8 12% PSEP Application QuestionsWhich professional field are you applying for?(Required) (Beginning 2024-2025)How did you hear about Nevada PSEP? Academic advisor Website Friend Relative Employer Practitioner Other Is this your first time applying for PSEP through the State of Nevada?(Required) Yes, this is my first time No, I have applied before Indicate the field and year you last applied: Have you applied for a federal program that provides support that requires a service obligation to the federal government upon graduation?(Required) Yes No Personal InformationName(Required) First Middle Last Email(Required) Phone(Required)Current 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 Do you have a permanent address that is different from your current address? Yes No Permanent 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 City / StateDate of Birth Educational InformationHigh School Graduated From:(Required) Location(Required) (City/State)Year Graduated College Graduated From:(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 Year Started (The year you started your currently active program)Student School Identification Number Estimated Graduation Date School PreferenceList, in order of preference, the professional schools to which you are applying.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 Pending 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 Pending Third 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 Pending Fourth 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 Pending Current or Most Recent EmploymentEmployer 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) Nevada Residency InformationTo qualify for residency for Nevada PSEP purposes, you must have been a bona fide resident of Nevada for at least 12 consecutive months prior to submitting your PSEP application. You will be required to provide proof of your Nevada residency (i.e., a Nevada driver’s license). We may request additional documentation to verify your Nevada residency.Are you a United States citizen or permanent resident?(Required) Yes No Are you a legal resident of Nevada?(Required) Yes No Specify State of Residence Start date of current residence(Required) (mm/yyyy)End date of current residence (mm/yyyy)County of Legal Residence Start date of residence in this county (MM/YYYY)End date of residence in county (mm/yyyy)Driver's License InformationDriver's License Number(Required) Date Issued(Required) State of Issue(Required)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 Please Upload Supporting DocumentsAttach 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 residenceAttach Program Acceptance Letter and Unofficial transcript if Currently Enrolled in 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 Please upload your unofficial transcript Certification and AgreementsAcknowledgement of Intent to Practice in Nevada(Required) I understand and agree to the followingUpon fulfillment of my professional studies, I will return, obtain my practice license, and practice my profession (employment) in the State of Nevada. Acknowledgement of Practice Duration in Nevada(Required) I understand and agree to the followingI will provide one (1) year of full-time practice in my profession for each year of Nevada PSEP stipend received.Acknowledgement of Intent to complete Practice Questionnaire(Required) I understand and agree to the followingI will notify the Nevada Office of WICHE of any changes related to my contact information and complete a Practice Questionnaire every six months with supporting documentation during school and out of school to demonstrate compliance with PSEP requirements.Acknowledgement of understanding for stipend requirements(Required) I understand and agree to the followingI 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 penalties.Acknowledgement of understanding for funding limitations(Required) I understand and agree to the followingI understand that continuation of Nevada PSEP stipends is subject to legislative appropriations and funding limitations; therefore, support cannot be guaranteed annuallyAcknowledgement of public release(Required) I understand and agree to the followingI 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. Consent to Transfer Student Records Through the Student Exchange Program(Required) I understand and agree to the followingWestern Interstate Commission for Higher Education PURPOSE FOR REQUESTING STUDENT SIGNATURE ON CONSENT AND WAIVER FORM: : Public Law 93-380, the Federal Family Education Rights and Privacy Act of 1974, requires all who hold custody of student records to insure protection of personally identifiable information. Administration of WICHE Student Exchange Program requires the exchange of educational information about student applicants in order to provide for consideration of enrollment and transfer of funds by the state in the case of admission by the school. In order to facilitate exchange of necessary documents, the student application is asked to sign a “Consent and Waiver” statement. DESCRIPTION OF USE OF PERSONAL RECORDS: The program collects and uses information concerning student eligibility for the program; admission; enrollment; academic progress; graduation and/or termination from the professional program; and payment of fees by the state through WICHE to the receiving school. This information is exchanged between and among the certifying office of the student’s home state; the staff of the Student Exchange Program, Western Interstate Commission for Higher Education; and the professional school(s) to which the student makes application and is admitted. The WICHE Commissioners of the sponsoring state may also review applications to consider eligibility of student(s). Periodic accounting for the Student Exchange Program in the state and in the region may result in publication of reports which may contain the student’s name, home state, year of enrollment, enrolling institution, and money spent by the state to support the student’s effort to reach an educational objective. NOTIFICATION CONCERNING STUDENT ACCESS TO PERSONAL RECORDS: Any student participant or applicant for participation in the Student Exchange Program has access to their personal records maintained as a part of the exchange activity. If you want to review your record, contact the Nevada Office of WICHE that maintains the record to make appropriate arrangements. Nevada Office of WICHE has 45 calendar days to comply. The student participant may inspect and/or receive copies at a cost not to exceed the actual cost of reproduction. Per Nevada Revised Statute 239.080 the Nevada WICHE Commission/Nevada Office of WICHE state record retention schedule for applicant files that are unfunded are retained five (5) years and recipient files are retained for twenty (20) fiscal years after contract satisfaction. After the retention period has ended the records can be destroyed securely. CONSENT AND WAIVER I understand that it is necessary to process student records in order to carry out the purpose of the Student Exchange Program, providing access to educational opportunities for residents of the western states. I understand that the record-keeping process requires preparation, transmission, receipt, filing, and reporting of information appropriate to the effectiveness and continuity of the program. I hereby consent to the transfer of personally identifiable educational records between and among the participants in the Student Exchange Program of the Western Interstate Commission for Higher Education to include the following: Information concerning student eligibility, acceptance, and educational attainment; Information concerning fees paid by the sending state through WICHE to the receiving school; Lists of applicants certified as eligible for support; Admissions reports, withdrawal reports, and annual reports for WICHE Exchange Students; Support agreement forms and invoices; and Special letters of inquiry and response as required to address questions and concerns identified by participants. I understand that the information referred to herein will be available only to Student Exchange Program staff members, designated institutional officials, and sending state officials as required to carry out their official duties. I further consent to the transfer of all or a portion of the above educational records to admissions officers and certifying officers as required to accommodate the needs of the Student Exchange Program provided that the officers receiving the information will not permit any other party to have access to such information without the express written consent of the undersigned. I hereby waive my right to receive specific notification of the transfer of such records. I understand that personally identifiable educational records will be used only to the extent necessary to carry out the purposes of the Student Exchange Program including reasonable research studies necessary to evaluate and improve the program. Any general research report of information that might prove harmful or embarrassing will be included only when anonymity is preserved. Use of the information will be permitted only when, in the judgment of the Student Exchange Program Director or other designated staff member, the request for information is wholly consistent with my best interest and the purpose of the Student Exchange Program. I understand that a log will be maintained to identify access to my records, which is permitted pursuant to law, and this information will be available to me upon appropriate request. Personal education records are securely stored electronically or in a locked file. 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 PSEP 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 PSEP application. Signature(Required)
