Form 001_FLRP FLRP_Application

HRSA–535 (04/96)

OMB NO. 0915-0150
Expires: 12/31/2009

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration
Bureau of Clinician Recruitment and Service
Division of Applications and Awards
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
1 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 10-33, Rockville, Maryland, 20857.
All Materials Submitted Become the Property of the Federal
Government and Shall Not Be Returned.
Fiscal Year 2010 Application
All fields marked with * are required.

1. *Professional Health Discipline
Discipline:
2. Your Full Name:
* Last Name:
* First Name:
Middle Initial:
Title:
Suffix:
3. Address
* Street Address:
* City:
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 this collection of information is estimated to average 1 hour 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 this burden, to HRSA
Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

HRSA–535 (04/96)

OMB NO. 0915-0150
Expires: 12/31/2009

* State:
* Zip Code:
4. * E-mail Address:
5. Telephone Numbers
a. Home:
b. Other (cell, office):
6. Citizenship/Gender:
(Proof of U.S. Citizenship or U.S. national status must be submitted with the application. This
may consist of a copy of your birth certificate that states your U.S. Citizenship, the ID page of
your U.S. passport, or a certificate of citizenship or naturalization.)
a. * Are you a citizen or national of the United States?
○ Yes

○ No

b. * Place of birth
City:
State:
Country, if not U.S.A.
c. Indicate Month, Day and Year of Birth:
d. Sex
○ Male

○ Female

7. Ethnicity/Race (Completion of this question is voluntary.)
Ethnicity (Mark only one)
Race (Mark all that apply)

○ Hispanic or Latino
○ Not Hispanic or Latino
□ American Indian or Alaska Native □ Pacific Islander
□ Native Hawaiian
□ Asian
□ Black or African American
□ White

8. * Has your school certified you as having a Disadvantaged Background? (If yes, documentation
must be provided by either your undergraduate or graduate school.)
○ Yes ○ No
9. a. *Do you have an existing service obligation?
Includes any outstanding contractual obligation for health professional service to the Federal
Government (e.g., an active or reserve military obligation or NHSC Loan Repayment Program) or
a State or other entity (e.g., State loan repayment program).
○ Yes ○ No
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 this collection of information is estimated to average 1 hour 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 this burden, to HRSA
Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

HRSA–535 (04/96)

OMB NO. 0915-0150
Expires: 12/31/2009

b. * If yes, when will the service obligation be complete?

10. * Are you enrolled as a full-time graduate or undergraduate student in the final year of a course of
study? (Physicians/Dentists in residency training should also complete this section.)
○ Yes ○ No
* Discipline:

(drop down menu)

* Expected date of graduation:

(drop down menu)

11. * Name of the professional school from which you received or will receive your professional
degree/certificate.
School name:
City:
State:
12. a. * In what year did you begin your work for this professional degree?
b. * In what year did you receive this professional degree?
c. * Type of degree/certificate obtained.
13. * Health professions school where you have contracted for employment (primary duties must
including teaching in a classroom).
School name:
City:
State:
Title:
Employed

○ Full-time

○ Part-time

14. * Total number of years teaching:
15. * Do you have a judgment lien against you arising from a Federal or non-Federal debt?
○ Yes ○ No
16. Are you debarred or suspended from any covered transactions by the Federal Government?
○ Yes

○ No

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 this collection of information is estimated to average 1 hour 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 this burden, to HRSA
Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

HRSA–535 (04/96)

OMB NO. 0915-0150
Expires: 12/31/2009

Explain:
17. * Have you defaulted on any Federal or non-Federal debt?
○ Yes ○ No
18. Have you had a Federal or non-Federal debt written off as uncollectible?
○ Yes ○ No
19. * Have you defaulted on a service obligation to a Federal, State, or local government entity, or
had a Federal service/payment obligation waived?
○ Yes ○ No
20. a. * Have you applied for any other loan repayment programs?
○ Yes ○ No
b. If yes, please provide the following:
Program name:
21. a. * Have you previously received a FLRP award?
○ Yes ○ No
b. If yes, please provide the following:
Years Funded _____ to _____
yyyy

yyyy

_____ to _____
yyyy

yyyy

_____ to _____
yyyy

yyyy

_____ to _____
yyyy

yyyy

22. How did you hear about FLRP? (drop down menu, make 1st line “choose one”)
Certification I certify that the information given in this Application is accurate and complete to 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 1001. 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).
1. Please review your application and check for errors, make changes, save and print a copy. View
your complete form.
2. You MUST print and sign a copy of this application form and submit it with all application forms
and supporting documentation to make your application complete. Incomplete applications will
not be considered.
3. For a complete list of necessary forms and supporting documents, please reference the Applicant
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 this collection of information is estimated to average 1 hour 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 this burden, to HRSA
Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

HRSA–535 (04/96)

OMB NO. 0915-0150
Expires: 12/31/2009

Information Bulletin.
The signed printout of your online Application Form MUST be mailed along with all application forms and
supporting documentation to:
Faculty Loan Repayment Program
Division of Applications and Awards
5600 Fishers Lane, Room 8-37
Rockville, MD 20857
Applications mailed after the deadline will not be considered for award.
If our review shows deficiencies or missing information you will be advised via e-mail. It is each
applicant’s responsibility to inform the FLRP of any changes to your application including, but not limited
to changes in work site, qualifying loan(s) information, contact information and e-mail address.

SUBMISSION OF THIS APPLICATION DOES NOT GUARANTEE FUNDING.

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 this collection of information is estimated to average 1 hour 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 this burden, to HRSA
Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.