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Application for Faculty Job Loan Repayment | DHHS HRSA BHP DHCDD

Application for Faculty Job Loan Repayment | DHHS HRSA BHP DHCDD

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Application for Faculty Job Loan DHHS HRSA BHP DHCDD

Guaranteed job teaching at University loan repayment
Application for Faculty Job Loan DHHS HRSA BHP DHCDD

Guaranteed job teaching at University loan repayment

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07/24/2010

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HRSA-535 (04/96)
OMB NO. 0915-0150
Expires: 12/31/2003
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESHealth Resources and Services AdministrationBureau of Health Professions
Division of Health Careers Diversity and Development
APPLICATION FOR THE FACULTY LOAN REPAYMENT PROGRAM (FLRP)
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 currently valid OMB control number. The OMB control number for this project
is 0915-0150. Public reporting burden for the applicant for this collection of information is estimated to average I hour perresponse, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. This burden is for Section I, IIA, and the contract.
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 Officer, 5600 Fishers Lane, Room 14-33, Rockville, Maryland, 20857.All Materials Submitted Become The Property of The Federal
Government And Shall Not Be Returned.
2003 Fiscal Year
1. NAME:
First
Last
Middle
2. CURRENT HOME
ADDRESS
Number
Apt.#
State
City
3. TELEPHONE
-
Home
Office
4. E-MAIL
5. PLACE OF BIRTH
state
city
Country
ARE YOU A CITIZEN OR NATIONAL OF THE UNITED STATES?
Yes
No
If you were born outside of the United States, you must submit (by mail / fax) documentation of naturalization
or other proof of U.S. citizenship.
DATE OF BIRTH
/19
-- -
 / 
 
RACE / ETHNICITY
(Completion of this question is voluntary and used for statistical purposes only)
Native Hawaiian or Other Pacific Islander
American Indian or Alaska NativeAsian - AllAsian - under-represented (defined as any Asian
 other than
Chinese,Filipino, Japanese, Korean, Asian Indian, Thai)Black or African AmericanHispanic or LatinoWhite
6. HAS YOUR SCHOOL CERTIFIED YOU AS HAVING A DISADVANTAGED BACKGROUND?
Yes
No
(If yes, have school official complete and submit certification form.)(If no, explain how you meet the disadvantaged background definition & provide supporting documentation.)
Requested effective date of HHS contract if other than August 1, 2003?
Reason:
7. HEALTH PROFESSIONAL GRADUATES
a. Name of school where you received your professional degree.
b. Location: City
State
c. In what year did you receive this professional degree?Yes
Nod. Did you complete a residency program?
If yes, date of completion
e. Type of degree obtained?
Yes
8. ARE YOU ENROLLED AS A FULL-TIME STUDENT?
No
Name of school where you are enrolled
Address
StreetState
CityZip Code
Phone # Where You Can Be Contacted
Expected Date Of Graduation9. SCHOOL CONTRACTED WITH TO SERVE AS FACULTY MEMBER.
(school name, city, and state)
Name of DepartmentTitle
No. of Yrs.
Full time
Part timeEmployed
 /  /
- -
 /
 
10. DO YOU HAVE AN EXISTING SERVICE OBLIGATION (OTHER THAN FLRP)?Yes
NoIf yes, name of the programMailing Address
StreetCityStateZip Code
Contact PersonTelephone NumberTerms of obligation
Yes
NoAre you m default of this obligation?When will this obligation be completed?I 1. ARE YOU APPLYING FOR ANY OTHER LOAN REPAYMENT PROGRAMS?
YESNO
If yes, name of the programMailing Address
StreetStateCityZip Code
Contact PersonTelephone NumberTerms of obligation12. DOES THE UNITED STATES HOLD A JUDGMENT AGAINST YOU?CreditorYes
No
Amount13. ARE YOU DEBARRED OR SUSPENDED FROM ANY COVERED TRANSACTIONS BY THEFEDERAL GOVERNMENT?
Yes
(please explain)
No
14. HAVE YOU PREVIOUSLY RECEIVED A FLRP AWARD?YesNo
15. HOW DID YOU FIND OUT ABOUT THIS PROGRAM?
CERTIFICATION
certify that the information given in this Application is accurate and complete to
I,
the best of my knowledge and belief. I understand that it will be investigated and that any willfully false representation issufficient cause for rejection of this application or if awarded a Loan Repayment, that I am liable for repayment of allawarded funds and, further, that any false statement herein may be punished as a felony under U.S. Code, Title 18, sectionI 00 1. I am aware that any false, fictitious, or fraudulent statement may, in addition to other remedies available to theGovernment, subject me to civil penalties under the Program Fraud Civil Remedies Act of 1986 (45 CFR 79).
SUBMISSION OF THIS APPLICATION DOES NOT GUARANTEE FUNDING.
- -
 /
- -

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