NHADA Student Grant - Student Authorization

NHADA Job Training Grant

Student/Employee Authorization
I am attending the following college :
I am applying for the :
I am authorizing CCSNH to discuss and release the following information with my employer listed below and NHADA Education Foundation and its employees.

Other
With my signature, I acknowledge this consent and authorization to be valid. I understand that this consent remains in effect until written revocation from me is received by the above-mentioned office/department/school. I also understand that such revocation does not affect disclosures previously made.
Student Information
Student Name
Date of Birth

MonthDayYear
Date
Signature
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
Student ID number
Address
City
State
Zip
Employer Information
Employer Name
Employer Address
Employer City
Employer State
Employer Zip
Service Manager Email
example@example.com
Service Manager Name
Course Information
Title of College Course(s)
Title of College Course(s) and Semester
CRN Number
Cost of Course
Questions? Please contact us at foundation@nhada.com or 603-224-2369
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NHADA Job Training Grant