LPX – Request Information Name* First Last Email* Phone*Zip* Program of Student*HVAC/RCDL-A TruckingCMAPhlebotomy/EKGMedical Billing & CodingMedical Office AssistantNetwork Administration & DesignDesktop Support TechnicianAre you a U.S. Citizen?* Yes, I am a U.S. citizen (or U.S. national) No Did you complete the 2020-2021 or 2021-2022 FAFSA?* I completed the 2020-2021 FAFSA I completed the 2021-2022 FAFSA I completed both I did not complete either Select all that apply:*If you are awarded the HEERF II grant, you, understand that the grant must be used toward components of your cost of attendance or for emergency costs that arise due to coronavirus. Select how you plan to use the grant. Must choose at least one. Tuition Food Housing Healthcare (including mental healthcare) Child expenses Respond to the prompt below:*In the space provided below please provide an explanation of how you have been impacted by Covid-19.Disbursement of funds:*If approved for the HEERF II student grant, the student has the option to receive a direct disbursement of the grant or to elect to apply the grant directly to their student account. If approved, do you wish to apply your HEERF II grant directly to your student account balance (tuition and standard fees)? Single choice. Yes, I would like to apply ALL the grant directly to my NTI account balance. I consent for this grant to be applied directly to my student ledger. Yes, I would like to apply PART of the grant directly to my NTI account balance. I consent for this grant to be applied directly to my student ledger. No, please disburse the grant directly to me. Amount of funds applied to student's tuition and fee balance*Student Signature* I am consenting that I am the person who has completed the HEERF II Application. I am allowing NTI to distribute my HEERF II funding in the manner that I have acknowledged on my application. I understand that in order to request changes or adjustments to how my funds are disbursed I must email HEERFII_grant@ntinow.edu. Adjustments on how funds are disbursed are not guaranteed and will be reviewed on a case-by-case basis.