South Dakota Technical Institutes Critical Needs Workforce ScholarshipAcceptance and Promissory Note for School Years 2014-15, 2015-16 and 2016-17

This form, and possibly other documentation requested by the Financial Aid Office, is required to validate and process Critical Needs Workforce Scholarship awards.

Technical Institute: Choose an item.Program of Study: Choose an item.

First Name: Click here to enter text. MI: Click Last Name: Click here to enter text.Soc.Sec.No.:

Click here to enter text. Anticipated Enrollment Semester/Year: Click here to enter text.

Permanent Street Address: Click here to enter text. City, State, ZIP: Click here to enter text.Area Code/Phone: Click here to enter text. Email: Click here to enter text.

REFERENCES: Provide two separate references with different US addresses, completed in full. A parent (if living) or legal guardian should be listed first.

First Reference Second ReferenceName: Click here to enter text. Click here to enter text.Address: Click here to enter text. Click here to enter text.City, State, ZIP: Click here to enter text. Click here to enter text.Area Code/Phone: Click here to enter text. Click here to enter text.Email: Click here to enter text. Click here to enter text.Relationship: Click here to enter text. Click here to enter text.

CERTIFICATIONS AND AUTHORIZATIONS - Please read and hand-initial each statement below. Do not type initials.Under penalty of perjury, I certify that: The information I have provided on this form is accurate and complete. I will enter the program of study noted above which will prepare me for employment in a critical need occupation in SD. I will enroll and maintain full-time status as a student and maintain a cumulative grade point average of 2.0 or higher. I will repay this scholarship, including any applicable collection costs and attorney fees, if I do not complete the program. I will work in South Dakota in the field I received training in for 36 consecutive months following graduation. I have up to 6 months

following graduation to secure a job in the field. If I do not begin employment in that field immediately following graduation, my 36 month employment commitment will begin as soon as I secure a job in the field.

I will repay the appropriate portion of this scholarship if I do not fulfill employment requirements for 36 months following graduation. I authorize the technical institute where I am enrolled and the SD Department of Education and its agents to release information about

me to certify and validate that I am eligible for the scholarship. I authorize the technical institute where I am enrolled, the SD Department of Education and the Governor of SD to release my name and

the name of my high school when announcing the critical needs scholarship recipients. I authorize the technical institute where I am enrolled to release pertinent information regarding this scholarship to the references listed

above unless I submit written direction otherwise. I authorize my employer(s) to release information to document my employment in the critical need occupation. I will provide necessary information 12, 24 and 36 months following graduation to document my employment in the critical need

occupation. I have read the information on page 2 of this Acceptance & Promissory Note and understand I will be bound by the terms and agreements outlined.

Please submit this completed form to the Financial Aid Office of the technical institute in which you will attend. Make a copy for your records.

I understand that by submitting this Acceptance and Promissory Note I am obligated to meet the eligibility and employment conditions outlined above. My failure to do so will result in me repaying the appropriate portion of the critical needs scholarship.

Student Signature Date

CRITICAL NEEDS SCHOLARSHIP PROGRAMSThe following technical institute programs of study have scholarships available:

LAKE AREA TECHNICAL INSTITUTE MITCHELL TECHNICAL INSTITUTE SOUTHEAST TECHNICAL INSTITUTE WESTERN DAKOTA TECH Energy Operations – AAS Energy Technology – AAS Precision Machining – AAS Precision Machining eDegree – AAS Robotics eDegree – AAS

Architectural Design & Building Construction – AAS

Automation Controls/SCADA – AAS Electrical Utilities and Substation

Technology – AAS Electrical Construction & Maintenance –

AAS/Diploma Farm Power Technology – AAS Heating & Cooling Technology –

AAS/Diploma Industrial Controls – Certificate Industrial Maintenance Technology –

Diploma Information Systems Technology –

AAS/Diploma Precision Technology Specialist –

AAS/Diploma Telecommunications – AAS Welding & Manufacturing Technology –

AAS/Diploma

Automotive Technician – AAS/Diploma CIS/Systems Administration – AAS Civil Engineering Technology – AAS Computer Network Security – AAS Computer Programming – AAS Computer Science – AAS/Diploma Diesel Technology – AAS/Diploma Electronics Technology – AAS/Diploma Land Surveying Science Technology –

AAS Mechanical Engineering Technology –

AAS Mechatronics – AAS Plumbing – Diploma Welding – Diploma

Computer Aided Drafting – AAS/Diploma Computer Science – AAS/Diploma Electrical Trades – AAS HVAC Technology – Diploma HVAC/R Technology – AAS Network Administration & Security –

AAS/Diploma Precision Machining – AAS/Diploma Transportation Technology – AAS Welding – AAS/Diploma

Once you receive a scholarship, the critical needs occupation remains eligible for meeting the employment requirement, even if the occupation ceases to be a critical workforce need in the state.

AGREEMENT I understand and agree that in the event I fail to

meet the scholarship eligibility requirements, I will no longer be eligible for additional funds and I will be required to repay my scholarship.

I understand and agree that if I fail to be employed in my training area or do not continue employment in the critical need occupation for 36 months, I will repay the appropriate portion of this scholarship. If I begin employment in the critical need occupation and leave before 36 months are complete, I will repay a prorated amount according to the policy of the technical institute where I received the scholarship.

I agree to inform the technical institute where I am enrolled within 10 days of any changes affecting my enrollment status, employment status, name or address.

The SD Department of Education or its agents may obtain enrollment and address information from any of the agents of the technical institute where I plan to be enrolled, am enrolled, or was enrolled.

REPAYMENTI further understand that repayment will be required if:

I cease full-time attendance without completing a program of study leading to employment in the critical need occupation, or

I am unsuccessful in completing my program of study at the technical institute where I am enrolled including withdrawal, unsatisfactory academic performance or conduct, or other factors due to my performance that prohibit me from continuing or graduating in the program, or

I graduate but do not obtain employment in the critical need occupation within 6 months in South Dakota, or

I cease employment in the critical need occupation in South Dakota without completing my employment obligation, or

I fail to fulfill the terms and agreements of the Acceptance and Promissory Note.

If I fail to make full payments, reasonable charges incurred for the collection and/or enforcement of this promissory note will be added to my repayment including, but not limited to, reasonable attorney’s fees and collection costs as determined by the technical institute where I am enrolled.

At its discretion, the technical institute where I am enrolled may allow me to continue receiving my scholarship if my enrollment status temporarily changes.

REPAYMENT BEGIN DATEIf I fail to meet the terms and agreement of the Acceptance and Promissory Note, repayment will begin 6 months following that date. Payment will be made to the technical institute in which I am enrolled and will include outstanding principal, applicable collection costs and reasonable attorney’s fees. The technical institute in which I am enrolled will provide me with the repayment amount for which I must make regular payments. I must make repayment regardless if I regularly receive a bill or repayment notice.

There will be no penalty for prepaying any portion and all payments will be applied in the following order:

1. Fees and collection costs2. Outstanding principal

DISCHARGEMy repayment obligation will not automatically be discharged in bankruptcy. I understand that this grant is educational and may be made in part through a non-profit

organization, and as such, may not be dischargeable in bankruptcy, except pursuant to 11.U.S.Code 523(a)(8).

The technical institute I am enrolled in does not vouch for the quality or sustainability of the academic programs offered. I understand I must repay the scholarship even if I do not complete my education, am unable to obtain employment in my field of study within 6 months of graduation, or I am dissatisfied with, or do not receive, the education for which I paid. It is my responsibility to secure a job in a critical need occupation in South Dakota.

The technical institute I am enrolled in may cancel my employment and/or repayment requirement, at its discretion, due to hardship.

ACCELERATION AND DEFAULTAt the option of the technical institute in which I am enrolled, the entire unpaid balance will become immediately due and payable (also called “acceleration”) if I:

Make a false representation that results in my receiving a scholarship for which I am not eligible or

Default

The following events shall constitute a default: I fail to pay the entire unpaid balance, I fail to make payment when due, provided my

failure has persisted for at least 270 days, or I fail to comply with other terms, and the technical

institute in which I am enrolled reasonably concludes I no longer intend to honor my repayment requirement. Principle balance, applicable collection fees and reasonable attorney costs will become immediately due and payable.

If I default, the default will be reported to all national credit bureaus and will significantly and adversely affect my credit history.

PRIVACY NOTICEThe information provided in this Acceptance and Promissory Note will be shared and released per the Certifications and Authorizations section. Your Social Security Number will be used as an account identifier and, should your critical needs workforce scholarship become payable, this information will be used in the servicing and collection of the loan.

TECHNICAL INSTITUTE USEScholarship Amount: Program CIP Code:

Scholarship Awarded for School Year(s):

CONTACT YOUR TECHNICAL INSTITUTE’S FINANCIAL AID OFFICE

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1201 Arrow AvenuePO Box 730Watertown, SD 57201605.882.5284 or 800.657.4344https://www.lakeareatech.edu/future/financialaid/financialaid.html

1800 East Spruce StreetMitchell, SD 57301605.995.3052 or 800.684.1969http://www.mitchelltech.edu/financialaid/

2320 N Career AvenueSioux Falls, SD 57107605.367.7624 or 800.247.0789http://www.southeasttech.edu/futurestudents/financialaid/

800 Mickelson DriveRapid City, SD 57703-4018605.394.4034 or 800.544.8765http://www.wdt.edu/financial-aid/

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