The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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Mississippi Office of Rural Health and Primary Care

Returning?

A A A

State Loan Repayment Program

Health Care Professional Application

For more information email questions to: slrp@msdh.ms.gov

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The option "" can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?

All form fields are required. Place N/A in fields that do not apply. You will not be able to submit until all fields are completed.

Name of Healthcare Professional:

Discipline:

NPI#:

Professional License#:

SS#: Date of Birth:

Home Street Address:

City:

State: Zip:

Phone:

Email:

How did you learn about the SLRP?

Demographics (for federal reporting purposes only)

Gender:

Ethnicity:

Race:

Primary Health Care

Yes No

Primary Health Care Profession:

Primary Health Care Specialty:

Dental Health Care

Yes No

Dental Health Care Profession:

Dental Health Care Specialty:

Mental Health Care

* must provide value

Yes No

Mental Health Care Profession:

Mental Health Care Specialty:

By completing this portion of the Health Professional application, I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of this information may subject me to administrative, civil, or criminal liability.

Are you under any service obligation with any entity that you agreed to serve for a specific period in a particular area or practice site (such as an employment sign-on bonus)?

Yes No

Please Explain:

Expand

By completing this portion of the Health Professional application, I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of this information may subject me to administrative, civil, or criminal liability.

Have you ever been a National Health Service Corps (NHSC) or another federal service program recipient?

Yes No

Please Explain:

Expand

By completing this portion of the Health Professional application, I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of this information may subject me to administrative, civil, or criminal liability.

Are you currently a National Health Service Corps (NHSC) or other federal service program recipient?

Yes No

Which program?

Expand

By completing this portion of the Health Professional application, I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of this information may subject me to administrative, civil, or criminal liability.

Have you ever applied for and been a National Health Service Corps (NHSC) or other federal service programs?

Yes No

Which program?

Expand

When did you apply and were denied?

M-D-Y

Proof of US Citizenship or US National (birth certificate, ID page of passport, or naturalized citizenship certificate) driver's license, and social security card are NOT acceptable proof of citizenship.

Proof of Mississippi professional license

Undergraduate Info

Name of School:
City:	State:
Degree:	Date Completed:

Name of School:
City:	State:
Degree:	Date Completed:

Graduate/Professional Info

Name of School:
City:	State:
Degree:	Date Completed:

Name of School:
City:	State:
Degree:	Date Completed:

Residency Info (if applicable)

Name of Site:
City:	State:
Date Attended:

Name of Site:
City:	State:
Date Attended:

Additional Training Info

Additional Postgraduate Training:

Date Attended:

By completing this portion of the Health Professional application, I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of this information may subject me to administrative, civil, or criminal liability.

Have you ever defaulted on a personal or student loan?

Yes No

Date of default:

M-D-Y

By completing this portion of the Health Professional application, I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of this information may subject me to administrative, civil, or criminal liability.

Were any personal or student loans ever under a federal court judgment?

Yes No

Date of judgement:

M-D-Y

By completing this portion of the Health Professional application, I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of this information may subject me to administrative, civil, or criminal liability.

Have you ever filed for bankruptcy?

Yes No

Date of bankruptcy:

M-D-Y

Select the number of loans you will be providing information on.

* must provide value

Lending Instituition Name:
Address:	City:
State:	Zip:
Loan Account#:	Type of Loan:
Original Amount:	Original Date:
Current Balance:	Current Balance Date:
Monthly Payment:
Purpose of the loan listed on the loan application:

Is this a consolidated loan?

* must provide value

Yes No

Was the loan sold?

* must provide value

Yes No

Seconday Lending Institution Name:
Address:	City:
State:	Zip:
Loan Account#:	Monthly Payment:

Original Loan Application & Agreement

* must provide value

Promissory Note

* must provide value

Disclosure Statement

* must provide value

Current Account Statement

Dated within 30 days of SLRP application

* must provide value

Statement from the current loan holder indicating:

Borrower's name
Original amount borrowed
Current loan balance
Monthly Payment
Date of disbursement
Type of loan

* must provide value

Lending Instituition Name:
Address:	City:
State:	Zip:
Loan Account#:	Type of Loan:
Original Amount:	Original Date:
Current Balance:	Current Balance Date:
Monthly Payment:
Purpose of the loan listed on the loan application:

Is this a consolidated loan?

* must provide value

Yes No

Was the loan sold?

* must provide value

Yes No

Seconday Lending Institution Name:
Address:	City:
State:	Zip:
Loan Account#:	Monthly Payment:

Original Loan Application & Agreement

* must provide value

Promissory Note

* must provide value

Disclosure Statement

* must provide value

Current Account Statement

Dated within 30 days of SLRP application

* must provide value

Statement from the current loan holder indicating:

Borrower's name
Original amount borrowed
Current loan balance
Monthly Payment
Date of disbursement
Type of loan

* must provide value

Lending Instituition Name:
Address:	City:
State:	Zip:
Loan Account#:	Type of Loan:
Original Amount:	Original Date:
Current Balance:	Current Balance Date:
Monthly Payment:
Purpose of the loan listed on the loan application:

Is this a consolidated loan?

* must provide value

Yes No

Was the loan sold?

* must provide value

Yes No

Seconday Lending Institution Name:
Address:	City:
State:	Zip:
Loan Account#:	Monthly Payment:

Original Loan Application & Agreement

* must provide value

Promissory Note

* must provide value

Disclosure Statement

* must provide value

Current Account Statement

Dated within 30 days of SLRP application

* must provide value

Statement from the current loan holder indicating:

Borrower's name
Original amount borrowed
Current loan balance
Monthly Payment
Date of disbursement
Type of loan

* must provide value

Lending Instituition Name:
Address:	City:
State:	Zip:
Loan Account#:	Type of Loan:
Original Amount:	Original Date:
Current Balance:	Current Balance Date:
Monthly Payment:
Purpose of the loan listed on the loan application:

Is this a consolidated loan?

* must provide value

Yes No

Was the loan sold?

* must provide value

Yes No

Seconday Lending Institution Name:
Address:	City:
State:	Zip:
Loan Account#:	Monthly Payment:

Original Loan Application & Agreement

* must provide value

Promissory Note

* must provide value

Disclosure Statement

* must provide value

Current Account Statement

Dated within 30 days of SLRP application

* must provide value

Statement from the current loan holder indicating:

Borrower's name
Original amount borrowed
Current loan balance
Monthly Payment
Date of disbursement
Type of loan

* must provide value

Lending Instituition Name:
Address:	City:
State:	Zip:
Loan Account#:	Type of Loan:
Original Amount:	Original Date:
Current Balance:	Current Balance Date:
Monthly Payment:
Purpose of the loan listed on the loan application:

Is this a consolidated loan?

* must provide value

Yes No

Was the loan sold?

* must provide value

Yes No

Seconday Lending Institution Name:
Address:	City:
State:	Zip:
Loan Account#:	Monthly Payment:

Original Loan Application & Agreement

* must provide value

Promissory Note

* must provide value

Disclosure Statement

* must provide value

Current Account Statement

Dated within 30 days of SLRP application

* must provide value

Statement from the current loan holder indicating:

Borrower's name
Original amount borrowed
Current loan balance
Monthly Payment
Date of disbursement
Type of loan

* must provide value

Lending Instituition Name:
Address:	City:
State:	Zip:
Loan Account#:	Type of Loan:
Original Amount:	Original Date:
Current Balance:	Current Balance Date:
Monthly Payment:
Purpose of the loan listed on the loan application:

Is this a consolidated loan?

* must provide value

Yes No

Was the loan sold?

* must provide value

Yes No

Seconday Lending Institution Name:
Address:	City:
State:	Zip:
Loan Account#:	Monthly Payment:

Original Loan Application & Agreement

* must provide value

Promissory Note

* must provide value

Disclosure Statement

* must provide value

Current Account Statement

Dated within 30 days of SLRP application

* must provide value

Statement from the current loan holder indicating:

Borrower's name
Original amount borrowed
Current loan balance
Monthly Payment
Date of disbursement
Type of loan

* must provide value

Lending Instituition Name:
Address:	City:
State:	Zip:
Loan Account#:	Type of Loan:
Original Amount:	Original Date:
Current Balance:	Current Balance Date:
Monthly Payment:
Purpose of the loan listed on the loan application:

Is this a consolidated loan?

* must provide value

Yes No

Was the loan sold?

* must provide value

Yes No

Seconday Lending Institution Name:
Address:	City:
State:	Zip:
Loan Account#:	Monthly Payment:

Original Loan Application & Agreement

* must provide value

Promissory Note

* must provide value

Disclosure Statement

* must provide value

Current Account Statement

Dated within 30 days of SLRP application

* must provide value

Statement from the current loan holder indicating:

Borrower's name
Original amount borrowed
Current loan balance
Monthly Payment
Date of disbursement
Type of loan

* must provide value

Lending Instituition Name:
Address:	City:
State:	Zip:
Loan Account#:	Type of Loan:
Original Amount:	Original Date:
Current Balance:	Current Balance Date:
Monthly Payment:
Purpose of the loan listed on the loan application:

Is this a consolidated loan?

* must provide value

Yes No

Was the loan sold?

* must provide value

Yes No

Seconday Lending Institution Name:
Address:	City:
State:	Zip:
Loan Account#:	Monthly Payment:

Original Loan Application & Agreement

* must provide value

Promissory Note

* must provide value

Disclosure Statement

* must provide value

Current Account Statement

Dated within 30 days of SLRP application

* must provide value

Statement from the current loan holder indicating:

Borrower's name
Original amount borrowed
Current loan balance
Monthly Payment
Date of disbursement
Type of loan

* must provide value

You are responsible for ensuring that each practice site location where you provide direct patient care services completes the SLRP Health Care Practice Site Application form and includes that form and all attachments with the application packet. List each practice site information below. Use as many additional pages as needed and add your name and discipline to the top of each page.

Please select the number of practice site locations where you provide direct patient care services.

* must provide value

1 2 3

Health Care Practice Site Name:

Address:

City:

Zip:

Medical/Dental Director Name:

Primary Point of Contact Name

Point of Contact Phone:

Point of Contact Email:

Date of Employment:

Hours worked per week:

Enter numerical value only

Hours providing direct patient care:

Enter numerical value only

Health Care Practice Site Name:

Address:

City:

Zip:

Medical/Dental Director Name:

Primary Point of Contact Name

Point of Contact Phone:

Point of Contact Email:

Date of Employment:

Hours worked per week:

Enter numerical value only

Hours providing direct patient care:

Enter numerical value only

Health Care Practice Site Name:

Address:

City:

Zip:

Medical/Dental Director Name:

Primary Point of Contact Name

Point of Contact Phone:

Point of Contact Email:

Date of Employment:

Hours worked per week:

Enter numerical value only

Hours providing direct patient care:

Enter numerical value only

Please upload your personal statement describing your training and experience working in underserved populations in Mississippi. Please include health disparities and describe how you, and the practice site, are trying to address these disparities. Describe your short and long-term goals and commitment to your practice site, including factors that influenced your decision to choose the community and practice site.

Personal statement must be typed and no longer than three pages in length.

Word or PDF file ONLY

I have read and understand the Guidelines and Instructions Document, which describes the Mississippi State Loan Repayment Program (MSLRP) requirements and affirm that I meet the qualifications for participation in the program. I authorize the MS State Department of Health Office of Rural Health and Primary Care to contact the listed employing health care practice site(s) and relevant licensing authorities for the purpose of obtaining information about my professional qualifications and experience.

I certify that the information given in this application and attachments is accurate and complete to the best of my knowledge. I understand that the information I have provided is subject to verification and that willfully providing false information may result in immediate disqualification from participation in this program. Any person who knowingly makes a false statement or misrepresentation in this loan application repayment transaction fraudulently obtains repayment for a loan or commits any other legal action in connection with this transaction is subject to repaying any amount received from this program, plus interest.

Once a contract is signed, any person who, through the legal contract, commits to serve and fails to complete the period of obligated services shall be liable to the State of Mississippi for an amount equal to the sum of the total amount paid to them under the contract as well as an unserved obligation penalty in an amount equal to 20% of the total amount paid out. The health care professional shall also forfeit any remaining allotments under the contract.

I have read this statement and understand its contents.

Application Date

* must provide value

M-D-Y

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