Form lrp community site lrp community site lrp community site form

OMB No. 0915-0127

Expiration Date:

NHSC Loan Repayment Program

Community Site Information Form

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 0915-0127. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, 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 the burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33 Rockville, Maryland, 20857.

If applicant works at more than one site, a separate Community Site Information Form must be completed for each site.

Applicant’s Name: ____________________________________________

Applicant’s Social Security Number: ______________________________

Applicant’s Discipline/Specialty: _________________________________

Site Name: ___________________________________________________

Site Address: _________________________________________________

City: _______________ State: _______________ Zip: _______________

Site Contact Person: ____________________________________________

Site Contact Email Address: ______________________________________

Site Phone Number: _________________ FAX Number: _____________

UDS Number: ________________________________________________

HPSA I.D. Number: ____________________________________________

HPSA Score: ___________________________________________________

I certify that I am currently in final negotiations with the above-named site for employment.

______ Check if applicable

I certify that I have completed negotiations with the above-named site.

______ Check if applicable

____________________________ ______________

Applicant’s Signature Date Signed

I certify that the above-named site is currently negotiating (or has negotiated) an employment contract with the above-named applicant.

__________________________ _______________

Executive Director Signature Date Signed