Healthcare Professional Application

Healthcare Professional Application

Healthcare Workforce Enhancement Program (HWEP)
Personal Information
Name*

First NameLast Name
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address*

Mailing Address

Street Address Line 2

CityState

Zip Code
Personal Phone Number*
Personal Email*
Do NOT use work email

Employer Information
Employer*
Position Title*
Employment Start Date*

MonthDayYear
Work Email*
Employer Sponsorship Form*

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This form must be completed and signed by your employer.

Visit the HWEP Portal to download.

Incentive
Select the incentive type you are applying for:*

Student Loan Repayment (LRP)Direct Incentive (DI)
Current Outstanding Student Loan Balance
For each loan, attach the following information

Recent Account Statement: Must be dated within 30 days of submission, showing loan balance and account details.

Loan Disbursement Report: Must show the original loan amount, loan purpose, and loan issue date.
Account Statement

Must be dated within 30 days of submission,showing loan balance and account details.
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Loan Disbursement Report

Must show the original loan amount, loan purpose, and loan issue date.
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Signature
I certify that the information provided in this application is accurate and complete to the best of my knowledge. I understand that providing false or misleading information may result in disqualification from the program or the requirement to repay funds disbursed.
First Name*
Last Name*
Date*

YearMonthDay
Should be Empty:

Personal Information