Form 003_FLRP FLRP_Inst Empl Repayment Form

OMB NO. 0915-0150
Expires: 12/31/09

Faculty Loan Repayment Program (FLRP)
Institution Employment/Loan Repayment Verification Form
The ________________________________________________________________________________ intends to employ
Institution (print or type)
__________________________________________________________________________________ in a faculty position
Applicant (print or type)
(duties primarily consist of teaching in a classroom) for a minimum of 2 years. The position is ___full-time (number of hours ____) or
___ part-time (number of hours ____). This employment must begin on or before September 30, 2009. Employment start date
__________________. Date Fall Term begins __________. Number of months in an academic year ______. Number of months
individual works as a faculty member _______.
Definition of full-time faculty position____________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
The institution is accredited by ________________________________________________________________________________
This information is for statistical purposes only. The institution is:
___ Historically Black
Located in a: ___ Medically Underserved Area (MUA)

___ Hispanic Serving

___ Tribal

___ Health Professional Shortage Area (HPSA)

The institution (must check one):
-----

-----

has agreed to make payments of principal and interest on the educational loans of the applicant in an amount equal to the
amount of such payment(s) made by the HHS Secretary (maximum $40,000 total for 2-year contract period). These payments
will be in addition to the applicant’s faculty salary and the applicant’s salary will be determined without regard to the amount
paid by HHS. Attach a copy of the agreement.
OR
is unable to make payments of principal and interest on the educational loans of the applicant in an amount equal to the
amount of such payment(s) made by HHS and requests a full or partial waiver of this requirement as an undue financial
hardship. (The Secretary may waive all or part of the institutional loan repayment requirement if the Secretary determines it
will impose an undue financial hardship on the school. The school must provide supporting documentation, as specified in the
Applicant Information Bulletin, to the applicant for submission with his/her application.) (If partial waiver is requested, amount
of funds that will be provided by institution per year: _____________) Attach a letter requesting a waiver and a copy of the
documentation.

Name: _______________________________________________________________________________________________
(print or type)
Title:

_______________________________________________________________________________________________

Mailing Address: ______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Phone: _______ - _______ - _________

ex _________

Fax : _______ - _______ - _________

E-mail: ______________________________________________________________________________________________
(print or type)
Signature : __________________________________________________________

Date: _________________

(4/09 - DAA, BCRS, HRSA, DHHS)
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 current OMB number. The OMB Number for this project is 0915-0150 and expires December 31, 2009. Public reporting burden for this
collection is estimated to average 60 minutes 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. 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 Office, 5600 Fishers Lane, Room 1033, Rockville, Maryland 20857.