Family Medicine Loan Repayment Incentive Application

Family Medicine Loan Repayment Incentive Application
Please Read Thoroughly Before Continuing

The Family Medicine Loan Repayment Incentive is designed to strengthen the physician workforce in rural and underserved communities across the state by ensuring that family doctors continue to live and practice in Tennessee after residency training.

This program provides student loan repayment of up to $40,000 per year to eligible family medicine residents for up to five years in return for a five-year work commitment in Tennessee following residency training. Selected applicants may receive up to $200,000 over five years.

The TNAFP Foundation Board of Directors will review and select applicants to receive funding during each reward cycle. The application will be open year-round, with the first recipients to be notified in the spring.

Before applying, please visit tnafp.org/fmloanrepayment/ to ensure your eligibility. Incentive funds may only be used for educational loan repayment.

This project is funded under a Grant Contract with the State of Tennessee.

Nondiscrimination statement: The TNAFP Foundation encourages all eligible individuals to apply for the Family Medicine Loan Repayment Incentive. No applicant shall be excluded or be otherwise subjected to discrimination on the grounds of handicap or disability, age, race, color, religion, sex, national origin, or any other classification protected by Federal, Tennessee State constitutional, or statutory law.
Personal Information
Full Name*

First NameLast Name
Email *
Please use a personal email address. Do not use a school or program email as access to those accounts will end after graduating.
What is your gender?*

MaleFemaleOtherPrefer not to say
Which race or ethnicity best describes you?*

American Indian or Alaskan NativeAsian/Pacific IslanderHispanicWhite/CaucasianMultiple ethnicity/Other (please specify below)
If you selected "Multiple ethnicity/Other," please specify here.
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Residential Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
What is Your Total Unpaid Educational Loan Balance (USD)?*
Name of Loan Carrier/Financial Institution:*
Residency Program Information

Please answer each of the following short answer questions:
Please select your residency program.*
Residency Graduation Date*

MonthDayYear
Anticipated Graduation Date
PGY Level *
Program Coordinator's Name*

First NameLast Name
Program Coordinator's Email Address*
Medical School Attended*
Medical School Graduation Date*

MonthDayYear
Date
Service Commitment

Awarded residents are required to complete a 5-year service commitment in a designated health professional shortage area regardless of the amount of funds awarded.
Desired area(s) or county in TN you wish to practice in (future employment)*
Have you accepted a job offer for future employment?*

YesNo
If yes, please list the name, full-time or part-time, and address of future employer:
If you have accepted a job offer for future employment, please upload the employment contract or signed employment verification letter here:

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Upload the following documents:

CV, Personal Statement, USMLE/COMLEX Scores, Letter of Recommendation, Medical School Transcript, Proof of U.S. Citizenship/Permanent Residency Status, Proof of Student Loan Debt, Personal Statement:
Upload CV*

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Upload Personal Statement*

Upload a personal statement which explains your connection and commitment to practice in a medically underserved area of Tennessee, as well as what type of practice you prefer. Why are you interested in participating in TNAFP Loan Repayment Program? Do you have any examples of your experiences and commitment to providing care to medically underserved populations? Also, be sure to address any gaps or extensions taken in medical school or residency.
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Upload USMLE/COMLEX Scores*

Please upload your USMLE/COMLEX scores. You may be awarded a stipend prior to passage of Step 3/COMLEX Level 3 but results must be shared with the Tennessee Center for Health Workforce Development when Step 3/COMLEX Level3 is completed.
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Upload Letter of Support from Residency Program Director*

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Upload Medical School Transcript*

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Upload Proof of U.S. Citizenship/Permanent Residency Status*

Accepted Documents Include: Passport, Birth Certificate, Certificate of Citizenship and Naturalization, Green Card, I-551 (Alien Registration Card)
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Upload Proof of Student Loan Debt Balance*

This program will not assist applicants with personal loan repayment.
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Submit Any Additional Applicable Documents Here

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Family Medicine Loan Repayment Incentive Application

Personal Information

Residency Program Information

Service Commitment

Upload the following documents: