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Nurse Apprentice Program ARPA Grant – Traveler EFT Form
Galina Tolle
2024-01-18T15:56:24-08:00
Nurse Apprentice Program ARPA Grant - Traveler Bank Account Setup
Step
1
of
3
33%
Date
MM slash DD slash YYYY
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!
*** 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)
Please select school
Antelope Valley College
Arizona College - Las Vegas Campus
Carrington College - Reno
Carrington College - Las Vegas
Chamberlain University
College of Southern Nevada (CSN)
Dixie Technical College (Utah)
EDP University of Puerto Rico
Galen College
Great Basin College (GBC)
Great Basin College - Pahrump
Grand Canyon University
International College of Health Sciences
Joyce University
Las Vegas College
Mojave Community College
Nevada Carrer Institute
Nevada State College
Nightingale College
Roseman University
Southern Utah University
Truckee Meadows Community College
Unitek College
University of Nevada, Reno (UNR)
University of Nevada, Las Vegas (UNLV)
University of Portland
Utah Tech University
Western Governors University
Western Nevada College (WNC)
Other
Other Nursing School
Please tell us where you are attending school so we can add it to the list.
Nursing Program
(Required)
Please selct one
Practical Nursing
Registered Nursing (Associate Degree)
Registered Nursing (Bachelor Degree)
Expected Graduation (Month)
(Required)
Select Month
January
February
March
April
May
June
July
August
September
October
November
December
Expected Graduation (Year)
(Required)
Select Year
2024
2025
2026
2027
2028
2029
2030
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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!
Bank Name
(Required)
Bank Routing Number ( ABA )
(Required)
Bank Account Number
(Required)
Bank Account Type
(Required)
Savings
Checking
When do want this change to go into effect?
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