W. Application Checklist

• The National Health Service Corps Loan Repayment Program application for 2008 will be submitted in two parts:
• On-line application must be submitted
• Supplemental forms must be downloaded, completed, printed, signed and sent by mail or delivery service
• Deadline for submission of both the application and supplemental forms is April 2, 2008.

A printable copy of this checklist is included in the NHSC LRP FY 2008 Supplemental Forms (Acrobat/pdf, 347 KB). You must download and print the form, initial each item, and sign and date the Checklist. Your signature indicates that you have read this Bulletin and that you understand all items required by the application. 

• Mail the completed and signed Checklist with your other paper application supplemental forms. 
• Keep a copy of the entire application package for your records and submit the original. 
• No application materials will be returned to applicants. 
• Deadline for application submission is April 2, 2008.

* Indicates that the checklist item must be dated after October 1, 2007

1. * Completed the on line application for National Health Service Corps (NHSC) Loan Repayment Program (LRP). 
2. * Completed Loan Information and Verification Forms for each loan for which you are seeking repayment assistance from the NHSC LRP.
3. Copies of your original loan applications, promissory notes, disclosure statements, and statements from current holder indicating the borrower’s name, amount borrowed, date of original disbursement, and type of loans.
4. Copy of complete loan payment history of previous awarded funds (applicable to past NHSC LRP award recipients.)
5. Copies of current account statement showing your loan balance for each loan submitted.  The current account statement must be dated not more than 90 days before the postmark date of NHSC application receipt. 
6. * Completed Payment Information Form.
7. * Completed NHSC LRP Community Site Information Form.  
8. * Completed Authorization to Release Information Form.
9. * Completed Certification of Accuracy of Information Provided Form.
10. * Signed and dated NHSC Loan Repayment Program Contract.
11. Copy of your health professional degree or certificate
12. Copy of your permanent license with an expiration date from the State in which you intend to practice.  Marriage and Family Therapists and Licensed Professional Counselors who are not required to have a license in the State in which they intend to practice must submit a copy of their license to practice independently and unsupervised from another State.  Also, if applicable, submit a statement describing any licensure restrictions.
13. * A copy of the entire response you receive in response to a self-query of the National Practitioner Data Bank and Healthcare Integrity and Protection Data Bank .  This includes the following documents:
    1. “Response to Your Self-Query”
    2. “NPDB Response to Self-Query” and any associated NPDB Reports
    3. “HIPDB Response to Self-Query” and any associated HIPDB reports

    For more information on obtaining these reports, see Section Q. of the Supplemental Forms (Acrobat/pdf, 347 KB). 

14. * Letters of reference from at least two individuals (including your current employer unless you are self-employed) who are in a position to evaluate your current clinical skills. If you are self-employed, one of the reference letters must be from the chief of the medical staff or the credentials committee at the hospital where you have admitting privileges (if you are a physician), or from an objective source such as a hospital or clinic credentials committee, a physician with whom you have a collaborative practice agreement, or the director of your training program (if you are not a physician). If you are a student or in a residency program, one reference letter can be from the director of your training program.
    Reference letters must be written on letterhead and include the following: a statement of the writer's relationship to you; an evaluation of your current clinical skills; the length of time the writer has known you in a professional capacity;  and the writer’s typed or printed name and telephone number.  These documents cannot be dated prior to October 1, 2007.
15. Proof of U.S. citizenship or status as a U.S National.  A copy of U.S. Passport, Birth Certificate, or Naturalization Certificate.
16. Power-of-Attorney (applicable if you are completing the application on behalf of another person)
17. Signed and dated Biographical Statement.
18. Copy of your specialty board certification or residency completion certificate (applicable to physicians and dentists.) 
    ** For new physicians and dentists in training, a letter of good standing from your residency program director is by the application deadline, April 2, 2008 and application and residency completion certificate is due July 1, 2008.   
19. Copy of your national certification (applicable to PAs, NPs, NMs, LPCs and some PNSs), or professional association membership (applicable to some MFTs).
20. Copy of your national board/licensing examination results (applicable to SWs, HSPs, and DHs). 
21. Copy of your current curriculum vitae/resume.
22. Letter, on business letterhead, from entity to which existing service obligation is owed indicating that the obligation will end on or before September 29, 2008 (applicable to applicants with existing service obligations).  Letter must state the nature of the obligation and the projected end date of the service obligation.  You must subsequently submit a letter from the entity verifying that your service obligation has been completed (except, if your existing service obligation is under the NHSC Scholarship Program).
23. Documentation of status as a member of a Reserve Component of the Armed Forces (applicable to applicants who are reservists)   
24. Proof of disadvantaged background from school official (where applicable)
25. Proof of exceptional financial need (EFN) scholarship (MDs, DOs, and dentists, where applicable).   
26. I know the current health professional shortage area (HPSA) score for the community site in which I am interested.  I understand a funding preference will be given to applicants serving in HPSAs of greatest need (based on the HPSA scores).    I understand awards will be made on an ongoing basis to eligible applicants with complete applications who propose to serve an NHSC community with a HPSA score of 14 or above.  I understand eligible applicants with complete applications who propose to serve an NHSC community with a HPSA score of less than 14 will not be funded until after the application deadline and will be funded after that date, by decreasing HPSA score, only to the extent funding remains available.
27. I have read this entire Bulletin and understand that it is my responsibility to submit a complete application.  I understand that my complete application must be submitted by the application deadline, April 2, 2008.  If my application is incomplete, I will not be considered for an FY 2008 NHSC LRP contract award.  Incomplete applications will not be reconsidered.
28. I understand that an NHSC LRP contract award cannot be part of my employment contract.  Community sites do not have any authority to guarantee an NHSC LRP contract award.
29. I understand that the NHSC LRP contract is not in effect until it is countersigned by the Secretary of Health and Human Services and his/her Designee.  I also understand that any practice at the NHSC community site before the contract takes effect is not eligible for NHSC loan repayments and will not count as NHSC service.
30. * Initialed, signed, and dated Checklist.

I have read and understand the items on this Checklist.

Name (Print)

Date

Signature

(Revised 01/08 - DAA, BCRS, HRSA, DHHS)