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O. CHECKLIST
O.M.B.:0915-0127�
Expiration August 31, 2010
Public
Burden Statement
An
agency may not conduct or sponsor, and a person is not required
to respond to, a collection of information unless it displays
a current OMB control number.� Public reporting burden for
this collection is estimated to average 60 minutes per response,
including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information.�
Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions
for reducing this burden, to HRSA Reports Clearance Office,
5600 Fishers Lane, Room 10-33, Rockville, Maryland 20857.
The National Health Service Corps
Loan Repayment Program Application Checklist
Application
Deadline - January 31, 2009 (postmark date)
You
must initial each item on this Checklist, and sign
and date the Checklist below. Your signature indicates that
you have read this Bulletin and that you understand
all items required by the application.� Return the Checklist
with your application.� Keep a copy of the application package
for your records, and submit the original.� No application
materials will be returned to applicants.� Deadline of application
submission is January 31, 2009 (postmark date).
* Indicates
that the checklist item must be dated after October
1, 2008
- *Completed
online application for National Health Service
Corps (NHSC) Loan Repayment Program (LRP).� �
- *Copy
of completed and signed online application.
- *Completed
Loan Information and Verification Forms for each
loan for which you are seeking repayment assistance from
the NHSC LRP. �The date
on this form should be within 1 week of the application
postmark date.
-
Copies of your original
loan applications, promissory notes, disclosure statements,
and statements from current holder indicating your name,
amount borrowed, date of original disbursement, and type
of loans.
-
Copy of complete
loan payment history of previous awarded funds
(applicable to past NHSC LRP award recipients.)
- *Copies
of current account statement
showing your loan balance for each loan submitted.
- *Completed
online BCRSIS
Banking Information Submission. �Go to HTTPS://NIS.HRSA.GOV/BANKLOGIN.ASPX�.
-
*Copy of completed and signed online BCRSIS Receipt
of Banking Information Submission (Confirmation Form).
-
*Completed NHSC LRP Community Site Information Form.
-
*Completed Authorization to Release Information Form.
- *Completed Certification of Accuracy of Information
Provided Form.�
-
*Completed Privacy Act Release Authorization form
(if applicable).
-
*Completed Certification Regarding Debarment, Suspension,
Disqualification and Related Matters form.
-
*Signed and dated NHSC Loan Repayment Program Contract.
-
Copy of your health professional degree or certificate
(or evidence that you have completed degree requirements).
- *Copy
of your current license and certification in the State
where you intend to practice with an expiration date.�
(NOTE: If your license will expire before September
30, 2009, please send in the license with the new
expiration date as soon as you receive it.)
- *Copy
of NPDB Response to Self-Query and any associated NPDB
reports and copy of HIPDB Response to Self-Query
and any associated reports.
- *Two
Letters of Reference (four if employed at your
current job less than 1 year).�
-
Proof of U.S. citizenship.�
- Power-of-Attorney
(applicable if you are completing the application on behalf
of another person).
- Signed
and dated Biographical Statement.
- Copy
of your specialty board certification or residency
completion certificate (applicable to physicians and
dentists.)� For physicians and dentists who will be completing
their residencies by June 30, 2009, a letter
of good standing from your residency Program Director
is due January 31, 2009 and residency
completion certificates or letters verifying residency
completion are due July 7, 2009.�
- Copy
of your national certification (applicable to PAs,
NPs, NMs, LPCs and some PNSs), or professional association
membership (applicable to some MFTs). �
- Copy
of your national board/licensing examination results
(applicable to SWs, HSPs, and DHs).
- Copy
of your current curriculum vitae (CV)/resume.�
The CV/resume must account for all periods of time following
graduation from the qualifying health professional program.
- Letter,
on business letterhead, from entity to which existing
service obligation is owed (if applicable) indicating
the date the service obligation will be completed.
- Documentation
of status as a member of a Reserve Component of
the Armed Forces (applicable to applicants
who are reservists).
- Proof
of disadvantaged background
from school official (where applicable).
- Proof
of exceptional financial need
(EFN) scholarship from a school official (MDs, DOs, and
dentists, where applicable).
- 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 first
to applicants with a Disadvantaged Background/EFN status
and second to applicants applying to serve in HPSAs of
greatest need (i.e., HPSAs with a score of 17 or
above). �If funding remains available, I understand
that awards will be made, by decreasing HPSA score, to
qualified applicants who propose to serve an NHSC community
with a HPSA score of less than 17.
- I
have read this entire Bulletin and understand that
it is my responsibility to submit a complete application.�
I understand what items must be submitted by January
31, 2009 (either electronically or by postmark
date).� If my application is incomplete as of the January
31, 2009 deadline, I will not be considered for
an FY 2009 NHSC LRP contract award.� Incomplete applications
and unsigned documents will not be reconsidered.
- 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.
- I
understand that the NHSC LRP contract is not in effect
until it is countersigned by the Secretary or 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
towards my NHSC service commitment.
- *Initialed,
signed, and dated Checklist.
I
have read and understand the items on this Checklist.
Applicant
Name (Print)
Date
Signature
of Applicant
(Revised
11/08 - DAA, BCRS, HRSA, DHHS)
Questions? nhsc@discoverylogic.com
or 1-800-638-0824 Monday through Friday (except Federal
holidays) 8:30 am to 5 pm ET.
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