Cybersecurity Public Service Scholarship Award
2022-2023 Institutional Verification Form
Maryland Higher Education Commission
Office of Student Financial Assistance
6 N. Liberty Street, Ground Suite
Baltimore, MD 21201
(410) 767-3300; (800) 974-0203
TTY for the Deaf - (800) 735-2258
Submit this form and all required documents to MHEC by SECURE UPLOAD online through your MDCAPS account. Once
logged in, selectElectronic File Upload” from the homepage then follow the prompts. This document and all
required documents must be submitted to MHEC by July 1, 2022 for consideration.
Section A - Student Inf
Social Security
Number: ____ ____ ____ - ___ ____ - ____ ____ ____ _____ Date of birth: _______/________/_______
Last name:
First name: MI:
City: State: Zip code:
Student Email:
Telephone #:
Degree Level:
Certificate Associate Degree Bachelor Degree Graduate Certificate Master Degree Doctorate Degree
Section B - Institution Information (All fields must be completed by the Register Office at your current institution.)
Name of Institution: ______________________________________________________________________________
Name of Person at the Institution Completing the Form: ___________________________________________
Email Address: Telephone #
Degree Program: _____________________________________________ Degree Program CIP: ___________
(Must match the CIP code listed on the MHEC
The # of credit hours completed to date in the d
egree program:____________________________
The # of credit hours remaining to complete in the degree program to satisfy graduation requirement: _______________
Is the applicant within 2 years of graduation from the Degree Program listed above?
What is the applicant’s Expected Graduation Date?______/_______/_______
Section C. Cybercorps Scholarship for Service Award Verification (Must be completed by the Register Office at the institution)
Applicants for the Cybersecurity Public Service Scholarship award are eligible for the award, if they never received a Federal
Cybercorps Scholarship for Service Award. Verification of whether the applicant has or hast not received the award must be
confirmed by the institution, check (√) as applicable below:
The applicant has received the Cybercorps Scholarship Award; or
The applicant has not received or applied for the Cybercorps Scholarship Award
By signing this form,
I acknowledge
that all information is accurate and consistent.
Signature of Student: ______________________________________ Date: ________________
Signature of Designated Institution Official____________________________________ Date: _________________
(Select One)
Please return the completed form to the applicant to be submitted with the application documentation. Forms not signed or completed
by the Register at the institution are INCOMPLETE and
not considered for the scholarship.
(Electronic Signature Acceptable; Typed Signature Prohibited.)
(Electronic Signature Acceptable; Typed Signature Prohibited.)