Practice Questionnaire Form

Recipients of our funding are required to report enrollment and/or employment status to our office every six months.

Please complete this form to comply with Nevada State law and your contracts.  Failure to comply may result in your grant being converted to a loan plus penalties and interest.

Certain documentation must be provided to complete this form and to verify your compliance with the funding requirements. Before beginning this form, you will need digital copies of the following:

If You Are Currently in School

  • Enrollment Verification Letter
    • Letter should be on institution official letterhead that includes address, issue date, student’s full name, program name, enrollment status (full or part-time), term (fall, spring, summer) and name, date, phone number, email, and signature of institutional representative verifying information.
  • Unofficial Transcript
  • Nevada Driver’s License
    • A photograph of the front of your Nevada Driver’s License.
    • If your license was issued within the year other options to document a minimum of one year of residency in Nevada is a copy of a lease agreement, rent receipts or utility bills.

If You Have Graduated and Are Completing Your Service Requirement

  • Employment Verification Letter
    • Letter should be on the employer official letterhead that includes address, issue date, employee full name, employment start and if not current, end date, position title, employment status and signature of employer representative verifying information. If employment status is not full time (40 hours) then the average number of hours completed per week should be indicated.
  • Nevada Driver’s License
    • A photograph of the front of your Nevada Driver’s License.
    • If your license was issued within the year other options to document a minimum of one year of residency in Nevada is a copy of a lease agreement, rent receipts or utility bills.
  • Practice License
    • Current licensure issued by the State of Nevada to practice in your field.