LOAN REPAYMENT PROGRAM APPLICATION FORM REGISTRATION

Please enter the information below to register your login for the Online Application Form. Once you complete and submit the information, you will have access to login and complete the online Application Form. All application materials must be submitted or postmarked by the deadline in order to be eligible. Applications which are not submitted by the deadline or are incomplete will be ineligible.

This online form is only one of several forms and documents that are required by the deadline in order for your application to be considered complete. To ensure that your application is complete, please refer to the checklist in the
Applicant Information Bulletin. The Applicant Information Bulletin outlines the eligibility criteria and the document/forms that are required.

If you have already registered? Login.

Please enter the information below. If you experience any problems, please contact the NHSC Loan Repayment Program Help Desk at nhsc@discoverylogic.com or (800) 638-0824.

*Fields marked with an are required.**

* Your Last Name:
* Your First Name:
Your Middle Initial:
* Street Address:
* City:
* State:
* Zip Code:
* Other Number (cell,office,etc):	- -
Discipline:
* Your Email Address:
* Reenter Email Address:
* Create Password:		Instructions: Password must be at least 8 characters long, and must include one character from at least 3 of the following 4 types: 1. Uppercase (A-Z) 2. Lowercase (a-z) 3. Numeric (0-9) 4. Symbol (~!@#$%^&*())
* Reenter Password:
* Create Security Question:
* Create Security Password: