Applicant Information Bulletin: School Year 2009-2010
Application Checklist

OMB NO. 0915-0150
Expires:  12/31/09

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 control number.  Public reporting burden for this collection is estimated to average 30 minutes per response, including 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 10-33, Rockville, Maryland 20857.

Application and banking information submitted electronically and printing “BCRSIS Receipt of Submission” deadline – July 7, 2009, 5:00 p.m. ET.

Signed copy of electronic application and “BCRSIS Receipt of Submission” and supporting documents deadline – July 7, 2009 (postmark date)

You must initial each item on this Checklist, and sign and date the Checklist below.  Your signature indicates that you have read this Bulletin, you understand all items required by the application, and you are certifying the truth and accuracy of the information submitted.  Return the Checklist with your application and supporting documents.  Keep a copy of the application and supporting documents for your records, and submit the original.  No application materials will be returned to applicants. 

1. Submitted electronic application for the Faculty Loan Repayment Program (FLRP) by July 7, 2009, 5:00 p.m. ET.
2. Copy of printed and signed electronic application.
3. Submitted banking information electronically through BCRSIS by July 7, 2009, 5:00 p.m. ET.  Go to HTTPS://NIS.HRSA.GOV/BANKLOGIN.ASPX and complete all requested payment information.  Upon completion, print out the “BCRSIS Receipt of Submission” and submit this form with the rest of your hard copy documentation.  If you are unable to print a copy of the “BCRSIS Receipt of Submission”, please complete the following 2 steps: 
   1)  Contact the HRSA Call Center to log a help-ticket toll-free at 1-800-221-9393 (TTY: 1-877-897-9910), Monday-Friday (except Federal holidays), 9:00 a.m. to 5:30 p.m. ET; and
   2)  Complete the Banking Update Form (SF1199A) which may be found at http://www.fms.treas.gov/eft/1199a.pdf.  The completed form must be received or postmarked by July 7, 2009. 
4. Copy of “BCRSIS Receipt of Submission”.
5. Proof of Disadvantaged Background from school official.
6. Completed Institution Employment/Loan Repayment Verification Form.
7. Copy of employment contract.
8. Copy of written agreement with employing institution to provide matching loan repayments (if applicable).
9. Letter requesting waiver and documentation of undue financial hardship to support your employing school’s request for a waiver of its loan repayment obligation (if applicable).
10. Completed Loan Information and Verification Forms for each loan for which you are seeking repayment assistance from the FLRP.
11. Copies of original promissory notes or disclosure statements, and statements from current holder indicating your name, amount borrowed, date of original disbursement, and type of loan.
12. Copy of complete loan payment history of previous awarded funds (applicable to past FLRP award recipients.
13. Copies of current account statement showing your loan balance for each loan submitted.
14. Signed and dated Faculty Loan Repayment Program Contract.
15. Completed Authorization to Release Information.
16. Copy of your Curriculum Vitae/Resume.
17. Proof of U.S. Citizenship or U.S. National status (e.g., copy of birth certificate, certificate of citizenship, passport, or naturalization certificate).
18. Copy of your health professional degree or certificate, if applicable.
19. Letter of good standing from your Program Director if you are in your last year of graduate training or school with expected date of graduation (if applicable).
20. Letter on business letterhead from entity to which existing service obligation is owed (if applicable) indicating the date the service obligation will be completed.
21. Completed Certification Regarding Debarment, Suspension, Disqualification and Related Matters Form.           
22. I have read this entire Bulletin and understand that it is my responsibility to submit a complete application.  I understand that my complete application and banking information must be submitted electronically by July 7, 2009, 5:00 p.m. ET, and the signed copy of my electronic application, “BCRSIS Receipt of Submission” and supporting documents must be submitted by July 7, 2009 (postmark date).  If my application, banking information and supporting documents are incomplete, I will not be considered for an FY 2009 FLRP contract award.    
23. I understand that a FLRP contract award cannot be part of my employment contract.
24. I understand that the FLRP contract is not in effect until is it countersigned by the Secretary or his/her designee.
25. Initialed, signed, and dated Checklist.

I certify that the information submitted in this application package is true, complete, and accurate to the best of my knowledge and belief and does not omit any material fact. I understand that the information given may be investigated and that any knowing and willful false representation, or concealment, of a material fact is sufficient cause for rejection of this application, or, if awarded loan repayment, that I am liable for the return of all awarded funds and, further, that any such false statement or concealment may be punished as a felony under 18 U.S.C. § 1001 and subject me to civil penalties under the Program Fraud Civil Remedies Act of 1986.

Applicant Name (print)

Date

Signature of Applicant