APPLICATIONS: Accepted on an ongoing basis. Facsimiles and electronic submissions accepted, if followed by a hard copy via postal delivery.Site Application must be submitted in conjunction withCandidate Application for full consideration. Please type or print responses.

1.Name:

Street Address:

City: State: Zip: County:

Phone Number: Work:

Email Address:

2.Are you a U.S. Citizen or national? Yes ____ No _____

Birth Date: Place of Birth:

If born outside of the U.S., please provide proof of citizenship.

3.Please check your profession/specialty below. The providers represented below are eligible for the Oregon Partnership State Loan Repayment program in 2012-13.

10/31/2012 SLRP Candidate App Page 1 of 4

___MD: Doctor of Allopathic Medicine

___DO: Doctor of Osteopathic Medicine

___DD: General Practice Dentist(D.D.S. or D.M.D.)

___PD: Pediatric Dentist

___NP: Primary Care Certified Nurse Practitioner

___NM: Certified Nurse-Midwife

___PA: Primary Care Physician Assistant

___DH: Registered Clinical Dental Hygienist

___HSP: Health Service Psychologist (Ph.D. or equivalent)

___CSW: Licensed Clinical Social Workers (master’s or doctoral degree in socialwork)

___PNS: Psychiatric Nurse Specialists

___MHC: Mental Health Counselors

___LPC: Licensed Professional Counselors (master’s or doctoral w/major study in counseling)

___MFT: Marriage and Family Therapists (master’s or doctoral w/majorstudy in marriage and family therapy)

___RN: Registered Nurses

___PharmD: Pharmacists

10/31/2012 SLRP Candidate App Page 1 of 4

4.Name of Professional School Attended:

Address: Dates Attended:

10/31/2012 SLRP Candidate App Page 1 of 4

5.Residency Program (if applicable):

Address: Dates Attended:

6.Are you Board Certified? Yes____ No_____Board Eligible? Yes____ No_____

Name of Board: Date of Certification:

7.License Information:

a)Type: d) Date Issued:

b)State: e) Expiration:

c)Number: f) Restrictions:

Has your license ever been restricted or revoked in any state? Yes____ No_____ (if yes, explain)

Are any professional disciplinary or legal actions pending in any state? Yes____ No_____ (if yes, explain)

8.Do you have an existing service obligation with any federal, state or other entity? Yes____ No____

If yes, please describe the obligation and when it will be completed. Please note that you are not eligible to participate in the SLRP if you currently have an outstanding contractual obligation for health professional service to the Federal Government, a State or other entity, unless that obligation will be completely satisfied before the SLRP contract will be signed.

9.Have you defaulted on any federal debt or have a judgment lien against you arising from a federal debt? Yes____ No_____ (if yes, explain)

10.Have you:

a) Defaultedon any student loans even if the creditor now considers you in good standing?
Yes____ No____

b) Defaulted on any Federal payment obligations (e.g., Health Education Assistant Loans, Nursing Student Loans, Federal Income Tax liabilities, FHA loans, etc)? Yes ____ No____

c) Breached a prior service obligation to any entity, even if you have subsequently satisfied the obligation? Yes ____No____

d) Had any Federal debt written off as uncollectible or had any Federal service or payment obligation waived? Yes ____No____

e) Ever been delinquent in child support payments? Yes ____No____

11.What is your approximate amount of outstanding student debt? $______

Please provide copies of all loans.

12.Personal contacts. List two individuals you will be in contact with during the next three years.

a)Name: Phone:

Complete Address:

b)Name: Phone:

Complete Address:

13.I have signed an employment agreement with an eligible clinical site to practice full-time.

Name of site:

Address: County:

(Sites must apply to be approved by the Oregon Partnership State Loan Repayment Program)

14.Qualifying education loans are governmental and commercial loans for actual costs paid for tuition and reasonable education (as defined in the SLRP Program) and living expenses (as defined in the SLRP Program) related to the undergraduate or graduate education of the participant, leading to a degree in the health profession in which the participant will satisfy his/her SLRP service commitment. Applicants must provide a copy of all qualifying loan documents (e.g., promissory notes). If an applicant has consolidated or refinanced loans, the applicant must provide a copy of the original loan documentation to establish the educational purpose and contemporaneous nature of such loans. If an eligible education loans is consolidated/refinanced with any other debt other than another eligible educational loan of the applicant, no portion of the consolidated/refinanced loan will be eligible for loan repayment.

15. On a separate sheet of paper, please describe the patient population to which you provide/will provide services including any health disparities experienced by that population.

16.On a separate sheet of paper, please describe how you, as a health care provider, will address these disparities and/or increase the health outcomes of the patient population (e.g.,community outreach/education, support groups, research)

17.References. Please provide letters of reference from at least three individuals (including your intended service obligation site) evaluating your suitability for participation in the Oregon Partnership State Loan Repayment Program. If you are a recent graduate or in a residency program you may include one reference letter from the director of your training program.

Reference letters must be written on letterhead and include the following: a statement of the writer’s relationship to you; an evaluation of your suitability for participation in this program; the length of time the writer has known you in a professional capacity; and the writer’s typed or printed name and telephone number.

I certify that the information given in this application and attachments is accurate and complete to the best of my knowledge. I hereby authorize the Oregon Office of Rural Health to contact references and program directors listed in the application for the purpose of obtaining information about my professional qualifications and experience. I understand that the information I have provided is subject to verification, and providing willfully false information will result in disqualification from participation in this program. I acknowledge receipt of the State Loan Repayment Program Information Notice.
SIGNATURE: DATE:
(Please sign your full name, in ink)

Please submit completed Candidate Applicationwith your Site Applicationto:

Oregon Office of Rural Health, L593

Oregon Health & Science University

3181 SW Sam Jackson Park Road

Portland, OR 97239

Questions about this program or application should be directed to Julie Hoffer, or 503.494.4450.

10/31/2012 SLRP Candidate App Page 1 of 4