Critical Needs Workforce Scholarship
Acceptance and Promissory Note
800 Mickelson Dr. - Rapid City, SD 57703
605-394-4034 or 800-544-8765
FAX: 605-394-2204
www.wdt.edu
2012-13 award year
Western Dakota Tech is pleased to offer you the Critical Needs Workforce Scholarship (CNWS). This form (and
possibly other documentation requested by the Financial Aid Office) is required to validate and process all CNWS awards.
PLEASE SUBMIT A TYPED APPLICATION
Name:
___________________________________
Soc. Sec. No.:
_______________________________
Address:
___________________________________
Phone:
_______________________________
City, ST, Zip:
___________________________________
Driver’s Lic #:
_______________________________
E-mail:
___________________________________
Date of Birth:
_______________________________
Anticipated Graduation Month/Yr:
Program of Study:
Electrical Trades
Welding (1-yr Diploma)
Welding (2-yr AAS)
REFERENCES - Please provide two separate references with different U.S. addresses, which must be completed in full. A
parent (if living) or legal guardian should be listed first.
First Reference
Second Reference
Name:
_________________________________
______________________________________
Address:
_________________________________
______________________________________
City, ST, Zip:
_________________________________
______________________________________
Phone Number:
_________________________________
______________________________________
Relationship to you:
_________________________________
______________________________________
CERTIFICATIONS AND AUTHORIZATIONS - Under penalty of perjury, I certify that (please read and hand-initial each
statement DO NOT TYPE YOUR INITIALS):
_____
The information I have provided on this form is complete and correct.
_____
I will enter the program of study I have noted above, which is a program identified by WDT and the State of South
Dakota, that will prepare me for employment in a critical need occupation in South Dakota.
_____
I will work in South Dakota in a critical need occupation in an industry identified by the State of South Dakota for 36
consecutive months upon graduation.
_____
I will repay this scholarship including any applicable collection costs and attorney fees if I do not complete the
program or fulfill the employment requirements of this scholarship.
_____
I will enroll and maintain full-time status as a student and maintain a cumulative grade point of 2.01.
_____
I authorize WDT, the SD Department of Education and its agents to release information about me to certify and
validate that I am eligible for the CNWS.
_____
I authorize my employer(s) to release information to document my employment in the critical need occupation.
_____
I have read the information on page 2 of this CNWS Acceptance & Promissory Note and understand I will be bound
by the terms and agreements outlined. Please note you MUST initial and date Page 2 of this form.
PLEASE SUBMIT THIS COMPLETED FORM TO THE WDT FINANCIAL AID OFFICE AT THE ADDRESSS LISTED ABOVE.
I understand that by submitting this Acceptance and Promissory Note, and that I will
obligated to meet the eligibility and employment conditions outlined, and my failure to do
so will result in the requirement to repay all CNWS funds received on my behalf.
Student Signature
Date
____________________________________________________________________________________________________________________
Western Dakota Tech is a public institution of higher learning where students acquire the knowledge, skills, and behaviors necessary for successful employment.
2012-13 CNWS Acceptance & Promissory Note
Page 2
Critical Needs Occupations
The South Dakota Department of Labor will designate critical
need occupations from time to time. The 2012-13 critical need
occupations for WDT are:

Electrical Trades

Welding
Once you receive a scholarship, the critical need occupation
remains eligible for meeting the employment requirement even
if the occupation ceases being a critical need.
Agreement
 I understand and agree that in the event I fail to meet the
eligibility requirements for the CNWS, I will no longer be
eligible for additional scholarship funds and I will be required
to repay my scholarship.
 I understand and agree that if I fail to be employed or
continue employment in a critical need occupation for 36
months upon graduation, I will be required to repay my
scholarship.
 I will comply with all CNWS rules and agree to inform WDT
within ten days of any changes affecting my enrollment
status, name, or address.
 The SD Department of Education and SD Department of Labor
or its agents may obtain enrollment and address information
from any of the officers or agents of WDT.
Repayment
I further understand that the repayment will be required if:
 I cease employment in critical need occupation in South
Dakota without completing my employment obligation, or
 I cease at full-time attendance without completing a program
of study leading to employment in critical need occupation; or
 I graduate but do not obtain employment in critical need
occupation in South Dakota
 I am unsuccessful in completing WDT’s Critical Workforce
Program, including withdrawal, unsatisfactory academic,
conduct, or other factors that due to my performance prohibit
the recipient from continuing or graduating in the program.
 I fail to maintain a cumulative gpa of 2.01 in the CNWS
program.
 I fail to fulfill the terms and agreement of the Acceptance and
Promissory Note
Repayment Begin Date
Your repayment date begins within six months of your failure to
meet the terms and agreement of the Acceptance and
Promissory Note.
I must make payment to WDT that will cover the outstanding
principal, applicable collection costs, and reasonable attorney’s
fees. WDT 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 costs; then
2.) Outstanding principal.
Discharge
My 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).
WDT does not vouch for the quality or suitability of the
academic programs offered. I understand I must repay the
grant even if I do not complete my education, I am unable to
obtain employment in my field of study, 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.
WDT may cancel my employment and/or repayment
requirement, at its discretion, due to hardship.
Acceleration and Default
At the option of WDT, the entire unpaid balance will become
immediately due and payable, (also called “acceleration”) if I:
 Make a false representation that results I 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 WDT 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 Notice
The 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 CNWS become
payable, this information will be used in the serving and
collection of the loan.
Questions and Contact Information
WDT’s CNWS program is administered cooperatively by the
WDT Financial Aid office and the WDT Foundation. Inquiries
can be directed to:
ATTN: Critical Needs Workforce Scholarship
800 Mickelson Dr. - Rapid City, SD 57703-4018
605-394-4034 or 800-544-8765
FAX: 605-394-2204
Student’s Initials: _______________ Date: ______________
____________________________________________________________________________________________________________________
Western Dakota Tech is a public institution of higher learning where students acquire the knowledge, skills, and behaviors necessary for successful employment.