HRSA-535 (04/96) OMB NO.

0915-0150
Expires: 12/31/2003

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration
Bureau 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 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. 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:
Last First Middle

2. CURRENT HOME
ADDRESS
Number Apt.#

City State

3. TELEPHONE - - - -
Office Home

4. E-MAIL

5. PLACE OF BIRTH
city state 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 Native
Asian - All
Asian - under-represented (defined as any Asian other than Chinese,
Filipino, Japanese, Korean, Asian Indian, Thai)
Black or African American
Hispanic or Latino
White

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? / /

d. Did you complete a residency program? Yes No

If yes, date of completion / /

e. Type of degree obtained?

8. ARE YOU ENROLLED AS A FULL-TIME STUDENT? Yes No

Name of school where you are enrolled
Address
Street

City State Zip Code

Phone # Where You Can Be Contacted - -

Expected Date Of Graduation / /

9. SCHOOL CONTRACTED WITH TO SERVE AS FACULTY MEMBER.

(school name, city, and state)
Name of Department
Title
Employed Full time Part time No. of Yrs.
10. DO YOU HAVE AN EXISTING SERVICE OBLIGATION (OTHER THAN FLRP)? Yes No

If yes, name of the program

Mailing Address
Street City State Zip Code
Contact Person

Telephone Number - -

Terms of obligation

Are you m default of this obligation? Yes No

When will this obligation be completed? / /

I 1. ARE YOU APPLYING FOR ANY OTHER LOAN REPAYMENT PROGRAMS? YES NO

If yes, name of the program

Mailing Address
Street City State Zip Code
Contact Person

Telephone Number - -

Terms of obligation

12. DOES THE UNITED STATES HOLD A JUDGMENT AGAINST YOU?

Yes Creditor No
Amount

13. ARE YOU DEBARRED OR SUSPENDED FROM ANY COVERED TRANSACTIONS BY THE
FEDERAL GOVERNMENT?
Yes (please explain) No

14. HAVE YOU PREVIOUSLY RECEIVED A FLRP AWARD? Yes No

15. HOW DID YOU FIND OUT ABOUT THIS PROGRAM?

CERTIFICATION
I, certify that the information given in this Application is accurate and complete to
the best of my knowledge and belief. I understand that it will be investigated and that any willfully false representation is
sufficient cause for rejection of this application or if awarded a Loan Repayment, that I am liable for repayment of all
awarded funds and, further, that any false statement herein may be punished as a felony under U.S. Code, Title 18, section
I 00 1. I am aware that any false, fictitious, or fraudulent statement may, in addition to other remedies available to the
Government, 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.


HRSA-535
CONTRACT FOR THE DISADVANTAGED HEALTH PROFESSIONS
FACULTY LOAN REPAYMENT PROGRAM
WITH
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
HEALTH RESOURCES AND SERVICES ADMINISTRATION
BUREAU OF HEALTH PROFESSIONS
Section 738(a) of the Public Health Service Act (''Act'') [42
United States Code 293 et seq.], as added by Pub. L. 102408,
authorizes the Secretary of Health and Human Services
(''Secretary'') to repay the educational loans of applicants from
disadvantaged backgrounds selected to be participants in the
Loan Repayment Program Regarding Service on Faculties of
Certain Health Professions Schools (''Faculty Loan Repayment
Program!'). In return for these loan repayments, applicants must
agree to provide teaching faculty services at an approved
accredited health professions school determined by the
Secretary for a designated period of obligated service pursuant
to section 738(a) of the Act.
Sections 738(a)(5)&(7) of the Act require applicants to submit
with their applications a signed contract with an accredited
health professions school and a signed contract which states the
terms and conditions of participation in the Faculty Loan
Repayment Program The Secretary shall sip only those
contracts submitted by applicants who are selected for
participation.
The terms and conditions of participating in the Faculty Loan
Repayment Program are set forth below:
Section A-Obligations of the Secretary
Subject to the availability of funds appropriated by the Congress
of the United States for the Faculty Loan Repayment Program,
the Secretary agrees to:
I - Pay, in the amount provided in paragraph 2 of this
section, the undersigned applicant's qualifying
educational loans. Qualifying educational loans
consist of the principal and interest on educational
loans received by the applicant for the following
expenses of enrollment:
a. tuition expenses;
b. all other reasonable educational expenses such as
fees, books, supplies, educational equipment and
materials required by the school, and incurred by
the applicant; or
c. reasonable living expenses as determined by the
Secretary.
OMB NO. 0915-0150
2. If the applicant agrees to serve 2 or more years:
a. Except as provided in subparagraph b. of this
paragraph, pay the following amounts of the
outstanding Principal and interest of a participants
nondelinquent educational loans for each year of
eligible faculty service:
Yr 1: $
Yr 2- $
b. The Secretary's liability will not exceed a cap of
$20,000 of principal and interest annually. This
would include the 10 percent waived under Sec.
738(a) of the Act for the schools proportionate share
of the loan repayment amounts. The applicant must
pay that portion not covered.
3. Make loan repayments for a year of obligated service no
later than the end of the fiscal year in which the
applicant completes such year of service.
4. The effective date of this Contract is: August 1. 2003
Section B-Obligations of the Participant
1. The applicant agrees to:
a. Continue loan repayments to lenders for the first
quarter after which the Secretary will make delayed
quarterly payments to applicant for the years stated in
paragraph c of this section. The applicant must pay
the lender(s) these payments.
b. Serve his or her period of obligated faculty service as
contracted with the school and as determined by the
Secretary to be acceptable.
c. Serve in accordance with paragraph b. of this section
for 2 years at
The applicant must serve a minimum of two years.
2. If the applicant's eligibility to participate in the Faculty Loan
Repayment Program is based on section 738(a)(2) of the Act
(i.e. based on-his or her enrollment in an accredited health
professions school), he or she also agrees to:
a. Maintain full-time enrollment in good academic
standing, as determined by the School, in the final year
of the course of study leading to a degree in medicine,
osteopathic medicine, dentistry, pharmacy, podiatric
medicine, optometry, veterinary medicine, nursmg,
public health, allied health and behavioral and mental
health practice in which the applicant is currently
enrolled, until completion of such course of study;
b. Enter into a contract with an accredited school
described in subsection (a) of Section 738 to serve as a
member of the faculty of the school for not less than 2
years according to the requirements described in
subsection (a)(5) of section 738.
C. Begin service obligation as contracted.
Section C-Breach of Written Loan Repayment Contract
I. If the participant fails to comply with section B.1.c. of this
contract or is dismissed for disciplinary reasons or
voluntarily terminates the contracts, neither the Secretary
nor the School is obligated to continue loan repayments as
stated in Sec. A of this Contract. The participant shall be
liable to the United States and the School for the amounts
specified in paragraph 2 of this section.
2. If the applicant agrees to serve as a full-time or part-time
faculty member for two years or more and fails to serve the
2-year minimum requirement he or she is liable to pay
monetary damages to the United States amounting to the
sum of (a) the total amounts specified in Section A.2 of
this contract plus (b) an unserved obligation penalty'' of
$ 1,000 for each month unserved as set forth in paragraph 3
of this section plus (c) any tax assistance paid plus (d)
interest penalties and administrative charges for past due
payments.
The Secretary or his/her authorized representative must sign this contract before it becomes effective.
Applicant Name
Applicant Signature
Secretary of Health and Human Services or Designee
3. The ''Unserved Obligation Penalty'' means the amount
equal to the number of months of obligated service that
were not completed by an individual, multiplied by
$ 1,000 except that in any case m which the individual
fails to serve 1 year, the unserved obligation penalty shall
be equal to the full period of obligated service multiplied
by $1,000.
4. If the applicant agrees to serve more than the 2-year
minimum service obligation and has completed the
2-year minimum he or she will be liable for such sum
paid for any months that are not a full year beyond the 2-
year minimum requirement as agreed to in Section B.1.c.
of this contract.
5. Any amount the United States is entitled to recover shall
be paid within one year of the date the Secretary
determines that the applicant is in breach of this written
contract. Failure to pay by the due date will incur
delinquent charges provided by Federal Law.
(45 CFR 30.13).
Section D-Cancellation, Suspension, & Waiver of
Obligation
Any service or payment obligation may be canceled,
suspended, or waived under certain circumstances described
below: (1) In the event of death or permanent and total
disability, the Secretary will cancel obligations under this
contract. To receive cancellation in the event of death, the
executor of the estate must submit an official death
certificate to the Secretary. To receive cancellation for
permanent and total disability, the applicant or his/her
representative must apply to the Secretary, submitting
medical evidence of the condition, and the Secretary may
cancel this obligation in accordance with applicable Federal
statutes and regulations; (2) Upon receipt of supporting
documentation the Secretary may waive or suspend service
or payment obligation under this contract if the Secretary
determines that: (a) meeting the terms and conditions of the
contract is impossible or would involve extreme hardship;
and (b) enforcement of the obligations would be
unconscionable. (3) Deferment will be granted in the event
of long term illness. Supporting documentation should be
sent to: FLRP, Bureau of Health Professions, Room 8-34
Parklawn Building, 5600 Fishers Lane, Rockville, MD
20857.
Date
Date
 Faculty Loan Repayment Program (FLRP)
Disadvantaged Background School Certification

Name of Applicant:
Name of Institution:

This letter certifies that the above named individual was determined to be from a
disadvantaged background, according to the FLRP definition, while attending this
institution. The individual was from an (choose one):
Environmentally Disadvantaged Background (Please provide specifics):

Economically Disadvantaged Background (Please provide the family size and family
income for the year(s), prior to the applicant entering college, based on applicant's
parent's Federal income tax returns in which the applicant was a dependent):

Certifying Official
Name: Date: / /

Title:
Phone: - - Fax: - -

E-mail:

WARNING: ANY PERSON WHO KNOWINGLY MAKES A FALSE STATEMENT

OR MISREPRESENTATION ON THIS FORM IS SUBJECT TO
PENALTIES WHICH MAY INCLUDE FINES AND IMPRISONMENT
UNDER FEDERAL STATUTE.
 Faculty Loan Repayment Program (FLRP)
Intention of Employment

The does not give 2 year

Name of Institution

contracts. It is the intention of this Institution to offer

Name of Applicant

a full-time or part-time (circle one); faculty position (duties will primarily consist of
teaching), for a minimum of 2 years (August 1, 2003 - July 31, 2005).

The institution is accredited by one of the eligible FLRP accrediting agencies.

The position was offered on / /

The institution agrees to (mark one):

make payments of principal and interest in an amount equal to the

amount of such quarterly payments made by the HHS Secretary.
These payments will be in addition to the applicant's faculty salary.

OR

request a waiver of its share of cost. (The Secretary may waive

the requirement if the Secretary determines it will impose an
undue financial hardship on the school.) The institution must
provide supporting documentation such as audit report, budget
report, etc.

Name: Date: / /

Title:

Address:

Phone: - - Fax - - -

E-mail:

WARNING: ANY PERSON WHO KNOWINGLY MAKES A FALSE STATEMENT

OR MISREPRESENTATION ON THIS FORM IS SUBJECT TO
PENALTIES WHICH MAY INCLUDE FINES AND IMPRISONMENT
UNDER FEDERAL STATUTE.