N.  Instructions for Completing the Application for the National Health Service Corps Loan Repayment Program

(O.M.B. 0915-0127) (Instructions are given only for selected items on the application.)

Power-Of-Attorney
If you are submitting and executing an application on behalf of another person, it is mandatory that a copy of the notarized agreement granting you current Power-of-Attorney be submitted with the application materials.    

SECTION I:  General

We frequently correspond with applicants by email.  Please make certain you check your email frequently during the application process for correspondence from our office and notify us promptly, in writing, of any changes made to your email address, address or phone numbers.

Item F.  Social Security Number

An applicant who is awarded an NHSC LRP contract will be required to provide his or her Social Security Number.  (See Privacy Act Notification Statement)  Applicants without a Social Security Number should apply for a number immediately by calling their local office of the Social Security Administration.

Item G.1. Citizenship, G.2. Place of Birth, & G.3. Date of Birth

Applicants must be a citizen of the United States (either born or nationalized) or a U.S. national to be eligible for an NHSC LRP contract award.  All applicants must submit proof of U.S. citizenship or status as a U.S National.  Proof of citizenship includes a copy of a birth certificate, a certificate of citizenship, passport, or naturalization certificate.  Permanent residents of the U.S. are not eligible.

Item H.  (a/b) Race/Ethnicity

Completion of this question is voluntary.  This information is used to measure the extent to which members of minority ethnic and racial groups apply for and receive NHSC LRP contract awards.  Answering or failing to answer this question will have no effect on your consideration for this program.

Item I.1. Existing Service Obligation, I.2. Month, Day and Year When Service Obligation Will Be Completed

Except as noted below, applicants already obligated to a Federal, State, or other entity for health professional practice are not eligible for the NHSC LRP unless that obligation will be satisfied completely on or before September 29, 2008.

Applicants who are currently members of a Reserve Component of the Armed Forces are eligible to participate in the NHSC LRP.  If you are a reservist, enter a "Yes" reply to Item I.1., and provide documentation of your status as a reservist.

Item J.1.  Former Exceptional Financial Need (EFN) Participant

This question is to be answered only by physicians (Allopathic and Osteopathic) and dentists.  If you answer “Yes”, enclose a copy of a statement from a school official.

Item J.2.  Disadvantaged Background

Some health professions schools provide financial or other assistance to students identified as having a "disadvantaged background."  If your school so identified you, indicate "Yes" here, even though you may not have actually received assistance, and enclose a copy of a statement from a school official certifying that you were identified as having a "disadvantaged background." Documentation must be submitted to confirm that your school identified you as having a "disadvantaged background."

Item K.  Availability to Begin Service Obligation

Indicate the date you began or will begin working at the NHSC community site.  Indicate the name of the community site and the city and State where it is located.  Applicants must begin employment at an NHSC community site on or before September 30, 2008.

SECTION II – EDUCATIONAL AND PRACTICE EXPERIENCES

Part A. Item 1.  Professional School Code

Print the name of the school and location.  Enter the professional school code number (see Appendix 2) corresponding to the name of the professional school from which you obtained your degree for the profession which would be utilized by the NHSC LRP.  Schools are listed by State, discipline, school code, and name of training facility.  Different disciplines taught at the same university will have different code numbers.  Be sure you use the code number representing the school you have attended and your discipline.  If the school code is not listed, please enter the code “9999".

Part A. Item 2.  Dates and Types of Degrees

In Item 2.a., enter the date you began your college or university education after high school.  This date is used to determine the first possible year for qualifying educational loans that NHSC LRP may repay.

In Item 2.b., enter the date you completed your work for the professional degree program you stated in Section I. Item A. This date is used to determine the last possible year for qualifying educational loans that NHSC LRP may repay. 

Part A. Item 4.  Completion of Residency Programs (For Physicians and Dentists)

If you completed training following the granting of your medical or dental degree that equips you to be certified in a specialty of your health discipline, mark "Yes."  For example, a M.D. who has completed a family medicine residency or a dentist who has completed a postgraduate year of general dentistry would indicate “Yes.” - If you had no training of this type (or did not complete such training), mark "No."

Part A. Item 5.  Completion Date of Residency Program (For Physicians and Dentists)

Residency must be completed and verification of completion must be submitted by the July 1, 2008.

Part A. Item 6.  Identify the Professional Residency Program From Which You Received Your Training (for physicians and dentists)

In Item 6.1., type the name of the program.

In Item 6.2., type the location of the program (city and state).

Part A. Item 7.  (For Mental Health Professionals)

Indicate in Item 7.a. whether you are eligible to practice your profession independently.  If you answer “No”, indicate in 7.b. when your supervisory period will be completed.  Your supervisory period must be completed and verification of completion must be submitted by the application deadline, April 2, 2008.

Part A. Item 9a., 9b., and 9c.  Are You Presently Holding a Permanent License?

You must be licensed in the State where you intend to practice under the NHSC LRP. See Section C.1.c. of this Bulletin.  In Item 9.b., please darken the circle for each State in which you hold a permanent license.  In Item 9.c., if you are not licensed in the State in which you would be serving, please indicate the month and year you plan to take the licensure examination for that State. Licensure must be obtained and verification of licensure must be submitted by the application deadline, April 2, 2008.

If licensure or certification as a Marriage and Family Therapist (MFT) or Licensed Professional Counselor (LPC) is not available in the State where you intend to practice under the NHSC LRP, you must have a license to practice independently and unsupervised as an MFT or LPC in another State. See Section C.1.c. of this Bulletin.  If you do not have such a license, please respond to item 9.c. by indicating the month and year you plan to take the licensure examination to practice independently and unsupervised in a State.  Licensure must be obtained and verification of licensure must be submitted by the application deadline, April 2, 2008.

Part A. Item 9d and 9e.  Licensure Restriction

Identify any type of restriction you have on your professional license in the space provided and enclose a separate statement explaining the restrictions.

Part B. Item 1., 2., 3., and 4.  Judgment Arising from a Federal Debt and Default on Any Debt.

In Item 1, applicants for the NHSC LRP must certify “Yes” or “No” that they do or do not have a judgment lien arising from Federal debt.

In Item 2, applicants for the NHSC LRP must certify “Yes” or “No” that they have or have not defaulted on any Federal debt or non-Federal loan.

In Item 3, applicants for the NHSC LRP must certify “Yes” or “No” that they have or have not had a Federal debt or non-Federal debt terminated (written off as   uncollectible). 

In Item 4, applicants for the NHSC LRP must certify “Yes” or “No” that they have or have not defaulted on a health professional service obligation to a Federal, State, or local government entity, or had a Federal service/payment obligation waived.

next page: Discipline, Specialty and Professional School Codes