2016 Application for STEM Occupations Loan Forgiveness Program Application period: May 2, June 16, 2016

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1 FOR OFFICE USE ONLY: Payment # Cohort # Approved 2016 Application for STEM Occupations Loan Forgiveness Program Application period: May 2, June 16, 2016 Not Approved Date of Action Reviewed By Do not submit this application prior to May 2, 2016 at 12:01am. Applications received prior to May 2 will be returned unprocessed. Completed applications must be received in the NDUS Financial Aid Office on or prior to June 16, Questions can be directed to ndfinaid@ndus.edu or Applicant Information (please print clearly) Name (Last, First, Middle Initial) as it appears on loan statement Social Security # Best phone # to reach you at Present Mailing Address City State Zip Code Education and Occupation Did you graduate from a campus STEM related major as defined in Table 1? Yes No If yes, the program CIP code for that major is:. (choose from Table 1 list) If your degree CIP code is not listed AND if you were funded in 2015 under this program, refer to the Table 1 & Table 2 Addendum for your code. List Standard Occupational Classification (SOC) number as defined in Table 2 (choose from list): - [A degree from Table 1 is required for Table 2 occupations to qualify.] If your job SOC code is not listed AND if you were funded in 2015 under this program, refer to the Table 1 & Table 2 Addendum for your code. Did you have a cumulative grade point average (GPA) of at least 2.5 on a 4.0 scale when you received your degree? [Note: GPAs will not be rounded-up.] Yes No REQUIRED: Attach copy of final college transcript showing degree earned, date completed and cumulative grade point average. If you were funded under this program in a prior year, you do not need to attach a transcript. Unofficial transcripts are acceptable. Loan Information Do not leave questions unanswered. If approved, I wish to have the following qualifying loan reduced under this program. Only loans NOT in default are eligible for consideration. Note that if you do not hold one of these types of student loans, you do not qualify for this program. Private alternative loans, except for the Bank of North Dakota DEAL Loan, do not qualify. You may list all of your outstanding student loan debt, however, the payment can only be applied to one loan. Payment will be applied to the loan with the largest balance unless you provide additional payment instructions in the far right column. You must have an outstanding balance on your student loan at the time of payment to receive loan forgiveness. Check qualifying non-defaulted loan type: Current outstanding loan balance: Additional payment instructions: FFEL Stafford (subsidized) $ FFEL Stafford (unsubsidized) $ FFEL Consolidated Loan $ Bank of North Dakota DEAL Loan or DEAL One $ Federal Direct Loan (subsidized) $ Federal Direct Loan (unsubsidized) $ Federal Direct Consolidated Loan $ Federal Perkins Loan $ If approved, I wish to have my loan forgiveness payment sent to the following holder of my student loan. This information must be complete and correct to ensure correct processing (do not leave any question blank): Name of financial institution or loan holder you make your payment to: Exact Payment Mailing Address City State Zip Code Student Loan Account Number (contact your loan servicer if unknown): # 1

2 Applicant Statement of Certification and Authorization I hereby certify that the information contained on this application is true and correct. I understand that I have the responsibility for applying for the STEM Occupations Student Loan Forgiveness program each year. I give my employer permission to release to the North Dakota University System any information that may be needed to verify my application. I give permission to the financial institution listed on this application to release to the North Dakota University System financial and loan information, and for the North Dakota University system to share with the financial institution and the Bank of North Dakota financial and loan information necessary to verify eligibility and process payment. I further understand that any STEM Loan Forgiveness payments made to my lender on my behalf must be applied only to outstanding balances on qualifying, non-defaulted loans. Any excess payment received by my lender, if any, must be immediately returned to the North Dakota University System. I must hold a balance on the qualifying loan at the time of payment to qualify. I understand that my application will not be considered if incomplete. Completed applications include page 1 and page 2 of the 2016 application, which includes the completed certification from employer(s) establishing 12 months of qualifying employment, and a final college transcript (transcript not required if funded under this program in a prior year). Unofficial transcripts are acceptable. I understand that I must be working within North Dakota to qualify. I understand that applications will be approved in priority order and that funding is contingent upon continued legislative appropriations. I acknowledge that any payment received under the STEM Occupations Loan Forgiveness Program may be considered taxable income for income tax purposes in the year it is written off. PRINT Applicant Name Signature of Applicant Date NOTE: If you had more than one employer in the past 12 months, you will need to make copies of this page and have each qualifying employer complete the Employer Certification below. Employer Certification (Personnel Director, CEO, or other company official who is authorized to certify employment must complete this section) I certify that with social security number of (name of applicant) was employed full time with within North Dakota at (name of company) (applicant s worksite location (city/state) within North Dakota) and works during the period of to in an occupation (date hired: mm/dd/yy) (date of termination or today s date if still employed mm/dd/yy) which can be classified as a STEM job occupation SOC code number - as defined in Table 2 (or Table 2 Addendum). Printed Name and Title of Authorized Official (Personnel Director or CEO, or other company official authorized to certify employment) Address Work Phone Number Signature of Authorized Official Date *Certifications may be subject to verification to establish applicant eligibility. If self-employed, your business must be a registered entity with the ND Secretary of State with a status of active and in good standing. Please return (on-or-after 5/2/2016) completed application, employer certification and final transcript (if required) to: North Dakota University System State Capitol, Judicial Wing 1 st Floor, Room E Boulevard Ave. Dept. 21 Bismarck, ND You may also fax to OR- upload a PDF file to the secure NDUS drop box at Please do not your documents. Thank you. Program authorized by N.D.C.C and administered by the State Board of Higher Education through the ND University System Procedure Awards are contingent upon continued legislative appropriations. 2

3 01 Agriculture, Agriculture Operations and Related Sciences Agricultural Mechanization, General Agricultural System Management NDSU Agricultural Mechanics & Equip/Machine Technology John Deere Technology NDSCS Agricultural and Food Products Processing Cereal Science NDSU Animal Sciences, General Animal Sciences NDSU Food Science Food Science NDSU Agronomy and Crop Science Plant Sciences NDSU Horticultural Science Horticulture NDSU Soil Science and Agronomy, General Soil Science NDSU 03 Natural Resources and Conservation Natural Resources/Conservation, General Environmental Technology Natural Resources Management DCB Natural Resource Management SBC Environmental Studies Earth System Science and Policy UND Environmental Science SBC Environmental Studies UND Studies in Community & Environment MiSU Environmental Science Environmental Science DSU, NHSC Natural Resources Management and Policy Natural Resources Management NDSU, CCCC Urban Forestry Urban Forestry Management DCB Wildlife, Fish and Wildlands Science & Management Fisheries and Wildlife Sciences VCSU Wildlife and Fisheries Technology DCB 04 Architecture and Related Services Architecture Architecture NDSU Environmental Design/Architecture Environmental Design NDSU Landscape Architecture Landscape Architecture NDSU North Dakota University System TABLE 1 STEM Degree Program CIP Codes 2016 Application 2010 Classification of Instructional Programs (CIP) 11 Computer and information Sciences and Support Services Computer and Information Sciences, General Computer Information Specialist NHSC Computer Information Systems MaSU, NDSCS, UMary, VCSU Computer Science DSU, UJms, MiSU, UND Information Technology Computer Information Technology UTTC Enterprise Application VCSU Information Technology UJms, SBC Computer Programming/Programmer, General Computer Science Basic Programming MiSU Software Systems Design RC Data Processing & Data Processing Technology/Technician Computer Technology Management DSU Information Processing WSC Information Technology MaSU Information Science/Studies Information Technology UMary Computer Systems Analysis/Analyst Information Systems UND Computer Science Computer Science NDSU, UND Scientific Computing UND Web Page, Digital/Multimedia & Info Resources Design Multimedia Technologies RC Web Development MiSU Web Page Development and Design BSC Computer Systems Networking & Telecommunications Computer Applications CCCC Computer Support Specialist BSC Information Technology DCB Microsoft Certified Network Administration NHSC System, Networking and LAN/WAN Management/Manager Information Technology WSC Web/Multimedia Management & Webmaster Information Technology Web Master DCB Computer and Information Sciences & Support Services Computer Information Systems (BAS) MaSU Computer Tech Support Specialist TMCC 3/21/ Education Educational/Instructional Technology Instructional Design & Technology UND 14 Engineering Engineering, General Engineering NDSU, UND Engineering Science UMary Agricultural Engineering Agricultural & Biosystems Engineering NDSU Chemical Engineering Chemical Engineering UND Civil Engineering, General Civil Engineering NDSU, UND Computer Engineering, General Computer Engineering NDSU Computer Software Engineering Software Engineering NDSU, VCSU Electrical and Electronics Engineering Electrical & Computer Engineering NDSU Electrical Engineering NDSU, UND Environmental/Environmental Health Engineering Environmental Engineering NDSU Environmental Geoscience UND Interdisciplinary Environmental Engineering (postbachelor certification) UND Materials Engineering Materials & Nanotechnology - NDSU Mechanical Engineering Mechanical Engineering NDSU, UND Petroleum Engineering Petroleum Engineering UND Construction Engineering Construction Engineering NDSU Industrial Engineering Industrial & Manufacturing Engineering NDSU Industrial Engineering & Management NDSU Manufacturing Engineering Manufacturing Engineering NDSU Surveying Engineering Environmental Technology, GIS - DCB Geological/Geophysical Engineering Geological Engineering UND Engineering, Other Sustainable Energy Engineering - UND CIP-1

4 15 Engineering Technology & Engineering Related Fields Engineering Technologies/Technicians Engineering Technology BSC Architectural Engineering Technology/Technician Architectural Drafting and Estimating Technology NDSCS Civil Engineering Technology/Technician Civil Engineering & Surveying Technology NDSCS Electrical, Electronic and Communications Engineering Technology/Technician Electric Power Technology BSC Electrical Transmission Systems Technology BSC Electronics Technology BSC Electronics/Telecommunications Technology BSC Electrical and Electronic Engineering Technologies/Technicians Electrical Technology - NDSCS Wind Energy Technician - LRSC Heating, Ventilation, Air Conditioning and Refrigeration Engineering Technology/Technician Heating, Ventilating, Air Conditioning & Refrigeration Technology NDSCS Energy Management & Systems Technology/Technicians Energy Auditor Program UTTC Energy Technician SBC Water Quality and Wastewater Treatment Management and Recycling Technology/Technician Environmental Technology Water Mgt DCB Water and Wastewater Technology BSC Environmental Engineering Technology, Environmental Technology Environmental Technology Laboratory & Field Technician- DCB Environmental Control Technologies/Technicians Renewable Generation Technology BSC Industrial Technology/Technician Industrial Technology UND Process Plant Technology - BSC Robotics Automation and Mechatronics Technology Mechatronics Technology - NDSCS Industrial Production Technologies/Technicians Power Plant Technology BSC Process Plant Technology TMCC Petroleum Technology/Technician Petroleum Engineering Technology BSC Petroleum Production Technology BSC, WSC Construction Engineering Technology/Technician Construction Management Tech NDSCS Surveying Technology/Surveying Geographic Information System Technician BSC Nuclear Engineering Technology/Technician Nuclear Power Technology - BSC Nanotechnology Nanoscience Technology - NDSCS Engineering Technology/Technicians, Other Energy Technology - NHSC 26 Biological and Biomedical Sciences Biology/Biological Sciences, General Biological Sciences NDSU Biology DSU, UJms, MaSU,MiSU, NDSU, UMary, VCSU Biology/Pre-Health UND Biochemistry Biochemistry UJms, NDSU, UND Molecular Biology Molecular and Integrative Biology - UND Biochemistry and Molecular Biology Biochemistry and Molecular Biology NDSU Plant Pathology/Phytopathology Plant Pathology NDSU Anatomy Anatomy UND Cell/Cellular and Molecular Biology Cellular & Molecular Biology NDSU Microbiology, General Microbiology NDSU Medical Microbiology and Bacteriology Microbiology UND Zoology/Animal Biology Zoology NDSU Entomology Entomology NDSU Wildlife Biology Fisheries & Wildlife Biology UND Genome Sciences/Genomics Genomics & Bioinformatics NDSU Pathology/Experimental Pathology Molecular Pathogenesis NDSU Pharmacology Pharmacology, Physiology & Therapeutics UND Biomathematics, Bioinformatics & Computational Biology, Other Bioinformatics & Computational Biology MiSU Biotechnology Biotechnology NDSU Environmental Biology Environmental & Conservation Sciences NDSU Biological and Biomedical Sciences, Other Science NHSC Tribal Environmental Science UTTC 27 Mathematics and Statistics Mathematics, General Mathematics DSU, NHSC, UJms, MaSU, MiSU, NDSU, UMary, UND, VCSU Applied Mathematics, General Applied Math UJms Statistics, General Applied Statistics NDSU Statistics NDSU 30 Multi/Interdisciplinary Studies Biological and Physical Sciences Math/Science Composite UMary Physical Science MiSU, UND Gerontology Gerontology NDSU 40 Physical Sciences Atmospheric Sciences and Meteorology Atmospheric Sciences UND Chemistry, General Chemistry DSU, UJms, MaSU, MiSU, NDSU, UND, VCSU Polymer Chemistry Coatings & Polymeric Materials NDSU Geology/Earth Science, General Geology MiSU, NDSU, UND Physics, General Physics MiSU, NDSU, UND 41 Science Technologies/Technicians Science Technologies/Technicians, Other Bio-fuels Technology NDSCS Biotechnology NDSCS Micromanufacturing Technology - NDSCS 43 Homeland Security, Law Enforcement & Related Protective Services Forensic Science and Technology Forensic Science UND 45 Social Sciences Econometrics & Quantitative Economics UND CIP-2

5 49 Transportation and Materials Moving Aeronautics/Aviation/Aerospace Science and Technology, General Aerospace Sciences UND Aviation UND Airline/Commercial/Professional Pilot & Flight Crew Commercial Aviation UND Aviation/Airway Management & Operations Airport Management UND Aviation Management UND Aviation Technology Management UND Air Traffic Controller Air Traffic controller UND Flight Instructor Flight Education UND Air Transportation, Other Space Studies UND Unmanned Aircraft Systems Operations UND 51 Health Professions and Related Programs Pharmacy Technician/Assistant Pharmacy Technician - NDSCS Veterinary/Animal Health Technology/Technician and Veterinary Assistant Veterinary Technology NDSU Emergency Medical Technology/Technician (EMT/Paramedic) EMT Paramedic Technology BSC Paramedic (EMT) Technology DCB, NDSCS Medical Radiologic Technology/Science/Radiation Therapist Radiologic Technology UJms, MiSU Respiratory Care Therapy/Therapist Respiratory Care NDSU, UMary Surgical Technology/Technologist Surgical Technology BSC Radiologic Technology/Science Radiographer Radiologic Science NDSU Radiologic Technology UMary Cytotechnology/Cytotechnologist Cytotechnology UND Clinical/Medical Laboratory Technician Medical Laboratory Technician BSC, RC Clinical Laboratory Science/Medical Technology/Technologist Clinical Laboratory Science MiSU, UMary Clinical Laboratory Science Management UND CLS Clinical Chemistry/Urinalysis UND CLS Hematology/Homeostasis UND CLS Immunohematology UND CLS Microbiology UND Medical Lab Science MaSU, NDSU, UND, VCSU Clinical/Medical Laboratory Science and Allied Professions Phlebotomy Technician BSC Pharmacy Pharmacy NDSU Public Health (MPH) Public Health - UND Veterinary Infectious Diseases International Infectious Disease Management and Biosecurity NDSU Registered Nursing/Registered Nurse Associate Degree Nurse LRSC Associate Degree Nursing WSC Nursing NDSU Nursing (RN) DSU Registered Nursing/Registered Nurse UND, MiSU, DCB, NDSCS, BSC Family Practice Nurse/Nursing Advanced Nursing Practice NDSU Family Practice Nurse/Nursing UND Licensed practical/vocational Nurse Training Practical Nurse DCB Practical nursing LRSC, DSU Licensed Practical/Vocational Nurse Training BSC, NDSCS, WSC 52 Business, Management, Marketing and Related Services Transportation Mobility Management Supply Chain Management BSC Transportation & Logistics NDSU Transportation and Urban Systems NDSU Management Information Systems, General Information Systems MiSU Information Technologies LRSC Information Technology Management RC Management Information Science UJms Management Information Systems MiSU, NDSU, UMary Management Information Systems and Services Applied Business Information Technology MiSU Information Systems Management RC Knowledge Management MiSU Information Technology Web Design DCB Indicates programs known to exist in North Dakota. Applicants graduating from comparable programs, based on CIP code, in other states are eligible when other program requirements are met. Acronyms: BSC = Bismarck State College, DCB = Dakota College Bottineau, DSU = Dickinson State University, NHSC = Nueta Hidatsa Sahnish College, UJms = University of Jamestown, LRSC = Lake Region State College, MaSU = Mayville State University, MiSU = Minot State University, NDSCS = North Dakota State College of Science, NDSU = North Dakota State University, RC = Rasmussen College, TMCC = Turtle Mountain Community College, UMary = University of Mary, UTTC = United Tribes Technical College, UND = University of North Dakota, VCSU = Valley City State University, WSC = Williston State College CIP-3

6 SOC OCCUPATION Computer and Information Systems Managers Industrial Production Managers Transportation, Storage, Distribution Managers Farmers, Ranchers, and Other Agricultural Managers Construction Managers Architectural and Engineering Managers Medical and Health Services Managers Natural Sciences Managers Manager, All Other Cost Estimators Computer and Information Scientists, Research Computer Systems Analysts Information Security Analysts Computer Programmers Software Developers, Applications Software Developers, Systems Software Web Developers Database Administrators Network and Computer Systems Administrators Computer Network Architects Computer Network Support Specialists Computer Occupations, All Other Actuaries Mathematicians Statisticians Mathematical Technicians Mathematical Science Occupations, All Other Architects, Except Landscape and Naval Landscape Architects Cartographers and Photogrammetrists Surveyors and Geodetic Surveyors Aerospace Engineers Agricultural Engineers Chemical Engineers Civil Engineers Computer Hardware Engineers Electrical Engineers Electronics Engineers, Except Computer Environmental Engineers Health & Safety Engineers, Except Mining Safety Engineers & Inspectors Industrial Engineers Materials Engineers Mechanical Engineers Mining & Geological Engineers, Incl. Mining Safety Engineers Petroleum Engineers North Dakota University System TABLE 2 STEM Occupation SOC Codes 2016 Application Source: SOC OCCUPATION Engineers, All Other Civil Engineering Technicians Electrical and Electronics Engineering Technicians Environmental Engineering Technicians Industrial Engineering Technicians Engineering Technicians, Except Drafters, All Other Surveying and Mapping Technicians Animal Scientists Food Scientists and Technologists Soil and Plant Scientists Biochemists and Biophysicists Microbiologists Zoologists and Wildlife Biologists Biological Scientists, All Other Conservation Scientists Foresters Medical Scientists, Except Epidemiologists Life Scientists, All Other Physicists Atmospheric and Space Scientists Chemists Environmental Scientists & Specialists, Including Health Geoscientists, Except Hydrologists and Geographers Hydrologists Economists Survey Researchers Social Scientists and Related Workers, All Other Chemical Technicians Geological and Petroleum Technicians Nuclear Technicians Environ. Science & Protection Technicians, Incl. Health Forensic Science Technicians Life, Physical, and Social Science Technicians, All Other Health Educators Community Health Workers Computer Science Teachers, Postsecondary Mathematical Science Teachers, Postsecondary Architecture Teachers, Postsecondary Engineering Teachers, Postsecondary Agricultural Sciences Teachers, Postsecondary Biological Science Teachers, Postsecondary SOC Forestry and Conservation Science Teachers, Postsecondary Atmospheric, Earth, Marine & Space Sciences Teachers, Postsecondary OCCUPATION Chemistry Teachers, Postsecondary Environmental Science Teachers, Postsecondary Physics Teachers, Postsecondary Economics Teachers, Postsecondary Health Specialties Teachers, Postsecondary Nursing Instructors and Teachers, Postsecondary Education Teachers, Postsecondary Criminal Justice & Law Enforcement Teachers, Postsecondary Secondary School Teachers, Except Special & Voc Ed Audio-Visual and Multimedia Collections Specialists Instructional Coordinators Multimedia Artists and Animators Commercial and Industrial Designers Graphic Designers Pharmacists Radiation Therapists Respiratory Therapists Veterinarians Registered Nurses Nurse Practitioners Medical and Clinical Laboratory Technologists Medical and Clinical Laboratory Technicians Radiologic Technologists Emergency Medical Technicians and Paramedics Pharmacy Technician Respiratory Therapy Technicians Surgical Technologists Veterinary Technologists and Technicians Licensed Practical/Vocational Nurse Fish and Game Wardens Computer Operators First-Line Supervisors-Farming, Fishing & Forestry Agricultural Inspectors Aircraft Mechanics and Service Technicians Farm Equipment Mechanics and Service Technicians Mobile Heavy Equipment Mechanics Heating, AC & Refrigeration Mechanics and Installers Water & Wastewater Treatment Plant & System Operators Chemical Plant and System Operators Chemical Equipment Operators and Tenders Airline Pilots, Copilots & Flight Engineers Commercial Pilots Air Traffic Controllers Airfield Operations Specialists 3/21/2016 SOC-1

7 TABLE 1 AND TABLE 2 ADDENDUM DO NOT USE THESE TABLES UNLESS YOU WERE FUNDED UNDER THE STEM PROGRAM IN 2015 AND ONLY IF YOUR DEGREE (CIP) CODE, OR JOB (SOC) CODE IS NOT LISTED ABOVE. The following codes have been removed from the STEM Loan Forgiveness Program beginning in the 2016 cycle. Only applicants who received funding under one of these CIP or SOC codes in 2015 are eligible to use these codes. The applicant s criteria will be evaluated to determine if they can be grandfathered into one of the following codes. Grandfather criteria: Must have been awarded (received funding) in the 2015 cycle under one of these codes. CIP Codes Removed Virtual Business Technology/Ind Arts Teacher Ed Mathematics Teacher Ed Science Teacher Ed Technical Teacher Ed Biology Teacher Ed Chemistry Teacher Ed Occupational Safety & Health Tech Lineworker Industrial Mech & Maintenance Automobile/Automotive Mechanic Diesel Mech Machine Tool Tech Welding Diagnostic Medical Sonography/Sonographer SOC Codes Removed Electro Mechanical Technicians Vocational Education Teachers, Postsecondary Middle School Teachers, Except Special & Vocational Education Career/Technical Education Teachers, Middle School Career/Technical Education Teachers, Secondary School Diagnostic Medical Sonographer/Ultrasound Occupational Health and Safety Specialists Computer, Automated Teller and Office Machine Repairers Electrical and Electronics Repairers, Commercial and Industrial Equip Automotive Service Technicians and Mechanics Bus and Truck Mechanics and Diesel Engine Specialists Industrial Machinery Mechanics Maintenance Workers, Machinery Electrical Power-Line Installers and Repairers Precision Instrument and Equipment Repairers, All Other Wind Turbine Service Technicians Machinists Welders, Cutters, Welder Fitters, Solderers and Brazers