Nurse Apprentice Program ARPA Grant – Traveler EFT Form

Nurse Apprentice Program ARPA Grant - Traveler Bank Account Setup

Step 1 of 3

Date

Action(Required)

New Traveler Setup

Updating Information

* You've selected "Updating Information" *

Please note: If you have already provided us with your banking information, this submission will overwrite what we have on file. Please contact us if you have questions or concerns!

What needs to be updated?

Contact Info (Name/Email/Phone/Nursing Program)

Residential Address

Banking Information

* You've selected "New Traveler Setup" *

Please note: You must reside more than 50 miles from the facility (one-way, shortest route, using google maps) to qualify.

Please contact us if you have questions or concerns!

Name(Required)

First Last

Email(Required)

Phone(Required)

Name of Nursing School(Required)

Other Nursing School

Please tell us where you are attending school so we can add it to the list.

Nursing Program(Required)

Expected Graduation (Month)(Required)

Expected Graduation (Year)(Required)

Address(Required)

Physical address only - No PO Boxes!

Street Address Address Line 2 City State ZIP Code

Proof of Address(Required)

We will need to verify proof of address in order to validate the mileage being requested to and from the facility. Upload a current form of documentation that shows proof of address. (i.e. driver’s license, utility bill, etc.)

Max. file size: 20 MB.

Name of Employing Facility(Required)

Expected Number of Miles(Required)

Please use Google Maps and enter the SHORTEST distance for ONE-WAY travel.

* INELLIGIBLE *

Please note: You must reside more than 50 miles from the facility (one-way, shortest route, using google maps) to qualify.

Please contact us if you have questions or concerns!

Nevada Nurse Apprentice Program

Nurse Apprentice Program ARPA Grant - Traveler Bank Account Setup

*** You've selected "Updating Information" ***

*** You've selected "New Traveler Setup" ***

*** INELLIGIBLE ***

* You've selected "Updating Information" *

* You've selected "New Traveler Setup" *

* INELLIGIBLE *