SHARP Practitioner Application

Page 2 - Education and Professional Information
Occupation *
Occupation specialty and/or other credentials
Year practice began in THIS occupation (first licensure, if applicable) *
Are you exempt from Alaska licensure? *

Yes No
If yes, reason:

List any current licenses you hold

State

License Number

Most recent effective date

Expiration date

Do you provide substance abuse treatment? *

Yes No
If yes, do you hold a specific certification in substance abuse treatment?

Yes No
If yes, name this credential:
Below, list your school, post-graduate or professional program, and residency program (if applicable), and graduation or completion date of the degree required for your employment. Please list schools and degrees from most to least advanced (or most recent first).
a) School, program, or residency name *
Degree (if applicable)
State or country *
Graduation or completion date *

Month Day Year
Date
b) School, program, or residency name
Degree (if applicable)
State or country
Graduation or completion date

Month Day Year
Date
c) School, program, or residency name
Degree (if applicable)
State or country
Graduation or completion date

Month Day Year
Date
If your answers to this section need further detail, please write your comments here:

Page 4 - Practice Site (Already-hired applicants only)
Complete the information requested below for the primary practice site at which you intend to fulfill your SHARP service obligation. A practice site is a location 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. *If you are not already hired, simply skip this page.
Site name
Employer
Physical Site Address

Street Address

Street Address Line 2

City

Postal / Zip Code
Work phone

Area Code Phone Number
Work email
example@example.com
Signature date of hire

Month Day Year
Date
Actual start date

Month Day Year
Date
Hours per week
Site representative (person) or employer contact, if known:
Name
Phone Number

Area Code Phone Number
Email
example@example.com
If your answers to this section need further detail, please write your comments here:

Page 6 - Loan Information
•   You must list all education loans or conditional service agreements for which you have a remaining balance whether or not they entail a service obligation.

•   Include only those loans incurred to finance your undergraduate or graduate education and training that led to the professional degree necessary for the position through which you will fulfill your SHARP service obligation.

•   If you have consolidated or refinanced any eligible loan with a non-education loan, no portion of the consolidated/refinanced loan is eligible for loan repayment and must not be listed below or included in your practitioner application lender verifications.

•   Please list the information about all of your current education loans/service obligations in the "Current Loans" section. Add as many lines as needed.

•   List all original education loans that have been consolidated in the "Original loans that have been consolidated" section.

• If you have no loans, please leave these tables blank.
Current Loans
Consolidated loans - For consolidated loans, enter each Original Loan Name. If you are unable to provide the original loan names, enter Not Available in the Original Loan Name column.
For each eligible lending agency listed, you will need to complete a Loan & Lender form; download and fill it out with your basic information, send it to your lending agency, and upon their return of the form to you, upload it below. Your SHARP application is not complete until these are completed and submitted. If the SHARP application deadline is approaching and the lending agency has not returned the form to you, you may upload (as a temporary solution) a screenshot of your loan total from the lender's website. If you upload this instead, you are responsible for sending the completed Loan & Lender form(s) to SHARP.applications@alaska.gov as soon as possible.
Upload completed Loan & Lender form(s) here.

Browse Files

Cancel of
If you have left the above tables blank, please confirm that it is because you are only applying for the direct incentive component of SHARP-3.

I am only interested in direct incentive.

Page 7 - Experience

Present chronology of directly relevant health care practitioner work experience. You may list up to three positions.
Position Title #1
Occupation (discipline)
Name of practice/agency
Position start date

Month Day Year
Date
Position end date

Month Day Year
Date
Clinical or admin supervisor
Supervisor email
Supervisor phone
Briefly describe position #1
Position Title #2
Occupation (discipline)
Name of practice/agency
Position start date

Month Day Year
Date
Position end date

Month Day Year
Date
Clinical or admin supervisor
Supervisor email
Supervisor phone
Briefly describe position #2
Position Title #3
Occupation (discipline)
Name of practice/agency
Position start date

Month Day Year
Date
Position end date

Month Day Year
Date
Clinical or admin supervisor
Supervisor email
Supervisor phone
Briefly describe position #3

Page 8 - Questions
Please describe those aspects of your personal, academic and/or employment history that you believe make you highly suited to provide healthcare to Alaska's underserved populations. (limit 150 words) *
Please feel free to provide any other comments that you believe will help SHARP to determine your eligibility and priority for this support-for-service program. (limit 150 words)
If you are selected for participation in Alaska's SHARP Program:
1. Do you commit to working at your employer's facility for the entire duration of the contract? *

Yes No
2. Do you accept that if you lose, or depart from, your initial job, this does not change or abrogate the SHARP Service Contract? Rather, this means you will find and secure other eligible employment. It also means that the SHARP Program must approve any change of employer. Unilateral change of site is grounds for contract default. *

Yes No

Page 9 - Final Attestation & Signature
I understand that submitting this Practitioner Application is not enough for eligibility and ensuing contract. An Alaskan employer must also submit its own Employer Application. To move forward, I will find/speak to my employer about the SHARP opportunity and their need to complete the Employer Application. *

Yes, I understand
I certify via my electronic signature below that all information and data contained in the here-attached SHARP Practitioner General Application, and in any other document(s) that I submit at any time, are accurate and can be substantiated by records review.

These documents and/or data include but are not limited to: work experience, education, practitioner background, occupational licensure, and any other concurrent service obligation(s).

I hereby certify, under penalty of revocation of my Alaska SHARP MOA service contract and other potential penalties, that to the best of my ability all submitted data are true. If selected for participation in Alaska's SHARP Program, and upon signature of a contract, I here commit to working at my employer's facility for the entire contract-specified period.
Please sign (use your cursor to draw in the box) *

Clear
Please go through all tabs to ensure that you have included all relevant and correct information. When you click SUBMIT, it will officially submit your final SHARP application:
Should be Empty:

SHARP Practitioner Application

Page 1 - Personal Information

Page 2 - Education and Professional Information

Page 3 - SHARP Support and Service Obligation

Page 4 - Practice Site (Already-hired applicants only)

Page 5 - Practice Site (if you are still searching for a job)

Page 6 - Loan Information

Page 7 - Experience

Page 8 - Questions

Page 9 - Final Attestation & Signature