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JOB TITLE:

Immediate Supervisor

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JOB TITLE:

Immediate Supervisor

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Hourly Rate Salary

Nature of the work and responsibilities

Reason for Leaving

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/ Month / Day Year

To*

/ Month / Day Year

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Street Address
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JOB TITLE:

Immediate Supervisor

Supervisor Title

Hourly Rate Salary

Nature of the work and responsibilities

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I understand and agree that the RSA Scholarship involves a payback obligation to the Rehabilitation Services Administration. This means that I will pay back - in working time within the public vocational rehabilitation program – the equivalent of two (2) years of employment for every one year (1) that I am supported by the scholarship. I also agree to keep accurate and up to date contact information on file with the Program for Rehabilitation Leadership at Georgia State University.

By selecting the "I Agree" button, you are acknowledging that you have read and agree to the terms in the statement above and you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.*

I Agree I Do Not Agree

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