Form 10-XXX Specialty Education Loan Repayment Program (SELRP) - Pro

SPECIALTY EDUCATION LOAN REPAYMENT
PROGRAM - PROGRAM STATUS VERIFICATION

PART I - EMPLOYEE CERTIFICATION AND AUTHORIZATION FOR RELEASE OF INFORMATION

CONSENT: I authorize the educational institution in which I am, or will be, enrolled to release to VA information regarding my medical
residency program status and standing. I understand that this authorization is voluntary, and that I may revoke this consent at any time. However,
I further understand that if I voluntarily revoke this authorization after the award of the scholarship, my award and placement with VA may be
terminated and I may be liable for the damages in accordance with provisions under the SELRP.
PARTICIPANT NAME:
PARTICIPANT SIGNATURE:

DATE:

PART II – PROGRAM DIRECTOR VERIFICATION
I verify the individual is in good standing and recommended for continued participation in the VA SELRP.
PROGRAM DIRECTOR NAME:
PROGRAM DIRECTOR SIGNATURE:

DATE:

PROJECTED MONTH AND YEAR OF RESIDENT’S PROGRAM COMPLETION:

VA FORM
JAN 2020

10-XXX

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