HCPWEP Application Form

Personal Information
Full Name*

First NameMiddle NameLast Name
Other Names Used:
Applicant Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Applicant Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Personal Email*
Please provide your personal email address, work email will be provided later in the application
Personal Phone Number*

Other Service Obligation (s)
Check any other service obligation(s) that you participated in or anticipate having:*

National Health Service Corps LRPNational Health Service Corps Scholars ProgramIndian Health Service LRPNurse Corps LRPWWAMI Medical School Tuition Service ObligationEmployer-provided sign-on bonus service obligation or moving expense service obligation, retention bonus, or productivity bonusNone of the above
When did/does your service obligation end?
Please provide any additional information regarding the above service obligation(s)
Please review and acknowledge the below statements*

Applicant must not have breached a prior service obligation to a federal/state/local government or other entity.Applicant must not have had any federal or non-federal debt written off as uncollectable or received a waiver of any federal service or payment obligation.
Experience in Rural or Underserved Areas: Outline your experience or familiarity with working in rural or underserved areas, including any previous employment or volunteer roles that have prepared you for serving in Alaska’s underserved communities *

0/300

Employment Information
Please provide the Employer and Practice Site at which you will provide medical, dental or behavioral health services to Alaskans. The employer is the health care system or organization that owns the practice site.
Employer*
Position Title*
List the Practice Site(s) you will be working at*
Employment Start Date*

MonthDayYear
Date
Work Email*
Please provide work email
Service level is defined as:

Full-time: Minimum of 36 hours per week, in no less than three days each week.

Half-time: Minimum of 20 hours per week, in no less than two days each week.
Service Level Applying for*

Full-TimeHalf-Time
Direct Patient Care Hours *
Expected percentage of weekly hours dedicated to providing direct patient care
Direct patient care activities include Clinical Services, Telehealth, and Case Management and Coordination.

Incentive
Select the incentive type you are applying for:*

Student Loan Repayment (LRP)Direct Incentive (DI)
Current Outstanding Student Loan Balance
Please attach a Lender Account Statement and Loan Disbursement Report for each loan to be considered.
Recent Loan Account Statement

Cancelof
Loan Disbursement Report

Cancelof

Required Attachment and Applicant Certification
Employer Sponsorship Form

Cancelof
Please use the space below to provide comments regarding any of your responses

0/300
Applicant Certification:

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.
Applicant Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Healthcare Professional Application Form