Get College Funds - Certification Form

2009-10 OSAC Scholarship Application Certification

Certification and Agreement
By checking each of the 6 checkboxes below, you certify that you have read, understood, and agree to the following certification statements.
1. By checking all 6 checkboxes, I certify the accuracy of my completed OSAC scholarship application form and all accompanying documents, and, if requested, agree to provide proof of this information. I also give permission to the Oregon Student Assistance Commission (OSAC) to request and use data from my Free Application for Federal Student Aid (FAFSA) as well as data and materials from this application to determine my eligibility for OSAC scholarships.
2. I authorize OSAC to share this information with scholarship processing and review staff, donors, and selection committees for identifying students, determining eligibility, and selecting and notifying awardees. I give permission to selection committees to contact high school and college officials for additional academic and/or financial information. I also allow my information to be shared with OSAC-approved researchers.
3. Under the Privacy Act of 1974, I understand I am not required to provide my Social Security Number; however, if I don't provide it, I will not be considered for OSAC need-based scholarships.
4. OSAC cannot guarantee applicants will receive scholarships. Further, by certifying this form, I agree to hold harmless, defend, and indemnify OSAC for any acts, failures to act, or omissions of the Commission, its employees, agents, volunteers, or any State of Oregon employee.
5. I have saved and printed a copy of my eApp and required documents and thoroughly reviewed it to ensure it is accurate and complete.
6. After my final submission, I understand that I may change only my name, address, e-mail, college choice, and major. I have verified that my essays, activities chart (school/family/community activities, volunteer service, and work for pay), and additional essays are complete.
Publicity Release
If selected to receive a scholarship, I give permission for a publicity release.		Publicity Release? Yes No
Applicant Data
Fill in your name, birth date, 5-digit eApp number (or the last 4 digits of your SSN if you did not apply online or cannot remember your eApp number), print the form, sign it, and date it, and send to OSAC.
Full Name:
Birth Date:
5-digit eApp Number (or last 4 digits of Social Security Number if you did not apply online or cannot remember your eApp number):
Signature: _________________________________________________
Date Signed: _________________________________________________

Send the completed certification form to OSAC ASAP (it must arrive at OSAC at least by the deadline listed on your eApp scholarship status page). We are starting to send out lists to scholarship selection committees, so the longer you delay, the fewer scholarships for which you will be considered.

Send by one of the delivery methods listed below, in order of preference:

Scan the completed form and e-mail it to transcripts@osac.state.or.us with the subject "Certification/Submission Form App ID XXXXX" where XXXXX is your 5-digit eApp application ID number
Fax the completed form during OSAC's business hours (8 a.m. to 5 p.m. PDT) to 541-687-7414, attention Scholarship Processing Coordinator
Mail or hand-deliver the completed form to:
Scholarship Processing Coordinator
Oregon Student Assistance Commission
Scholarship and Access Programs
1500 Valley River Drive, Suite 100
Eugene, OR 97401-2148