Form 1 FY 2017 NHSC S2S LRP Application Content

The National Health Service Corps Scholarship Program, Students to Service Loan Repayment Program, and the Native Hawaiian Health Scholarship Program

FY 2017 NHSC S2S LRP Application Content

NHSC Students to Service Program Application

OMB: 0915-0146

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0915-0146 can be found here:

Document [pdf]

Download: pdf | pdf

Students to Service Loan Repayment Program

National Health Service Corps Students to Service Loan
Repayment Program
Welcome to the FY17
National Health Service Corps Students to Service Loan
Repayment Program Online
Application
Thank you for your interest in the National Health Service Corps (NHSC)
Students to Service (S2S) Loan Repayment Program
(LRP). Please be sure to
carefully read the
2017
NHSC S2S LRP Application and Program Guidance (APG)
before starting
the application. The NHSC S2S LRP application consists of two parts: the
online application and required supporting
documents.
All applicants must be in their last year of medical or dental school
at an accredited school located in a State, the District of
Columbia, or a U.S. territory:
A school of allopathic medicine, pursuing an M.D.
degree, accredited by the Liaison Committee on Medical Education
(sponsored by the American Medical Association and the
Association of American Medical Colleges); or
A school of osteopathic medicine, pursuing a D.O.
degree, accredited by the American Osteopathic Association
Commission on Osteopathic College Accreditation; or
A school of dentistry, pursuing a D.D.S or D.M.D degree,
accredited by the American Dental Association, Commission
on Dental Accreditation.
Medical Students must plan to match and complete an
accredited primary care medical residency in an NHSC-approved
specialty. The approved residencies and time period for each
under the NHSC S2S LRP are:
Approved Residencies for Medical Students

Time Period

Family Practice

3 years

General Internal Medicine

3 years

General Pediatrics

3 years

Obstetrics-Gynecology

4 years

Internal Medicine/Family Practice

4 years

Internal Medicine/Pediatrics

4 years

Geriatrics Fellowship following completion of
residency training in Family Practice or General Internal

1 year

Medicine
Rotating internship with a request to complete a
residency in one of the above specialties

1 year

The NHSC S2S LRP may approve, on a case-by-case basis, and consistent with the needs of
the NHSC, additional
residencies not listed above. Proof of participation in an NHSC-approved
postgraduate training program will be required before
any loan repayments will be disbursed.
Dental students are encouraged, but not required, to complete one accredited postgraduate training in an NHSCapproved specialty. The list of NHSC-approved
postgraduate training programs, and the time period for each under the
NHSC S2S LRP, are
as follows:
Approved Postgraduate Training for Dental Students

Time Period

General Practice Dentistry

1 year

Advanced Education in General Dentistry

1 year

Pediatric Dentistry

2 years

Public Health Dentistry

2 years

Geriatrics Dentistry Fellowship following completion of postgraduate training

1 year

The NHSC will not approve any other postgraduate training programs and dental students who wish to pursue training other
than the postgraduate training programs listed above are advised not to apply for participation in the NHSC S2S LRP.
It is recommended that prior to beginning the
online application you prepare all electronic copies of the
required
supporting documentation. All information
provided in the supporting documents and online application
must match

https://testbcrs.hrsa.gov/beta/extranet/application/s2s/private/landing.seam?cid=98[5/1/2017 5:27:44 PM]

Students to Service Loan Repayment Program

exactly. Any disparities will cause your application
to be deemed ineligible.
All of these documents can be uploaded online:
Proof of U.S. Citizenship or U.S. National
Authorization to Release Information
Verification of Good Standing
Unofficial Transcript
Application Essays
CV/Resume
Letters of Recommendation
Proof of Passage of Required Licensure Exams
Loan Information Verification
Verification of Disadvantaged Background (If Applicable)
Existing Service Obligation/Reserves Document (If
Applicable)
All information provided in the supporting documents and online application must match. Any
disparities may cause your
application to be deemed ineligible.
The online application consists of the following sections:
1. Eligibility
2. General Information
3. Education
4. Letters of Recommendation
5. Loans
6. Supporting Documents
7. Self-Certifications
8. Review and Submit
The first section determines your eligibility. You will not be able to continue with the application
if you are found ineligible
based on your responses in this section. In addition, you will not be
able to move forward to the next section of the application
until you have completed all
required fields in the previous section. You will have the opportunity to save your application to
continue at a later date.
Prior to submission, you will have the opportunity to review and/or edit your application. Before
submitting your application,
you should review each section to verify that each is complete and
represents the information you want to submit. Once the
online application has been submitted,
applicants will also have an opportunity to make edits or withdraw their applications.
Final edits
and resubmissions must be made before the close of the online application portal (May 30, 2017).
You will not be
able to edit your submitted application after the application deadline. Your submitted
application will be available for download
and print.
Please select "Start My Application" to begin your online
application.
The final submission date is May 30, 2017 at 12:00 AM EDT. Remember to log
into the NHSC S2S LRP online application to
check the status of your
application!

Start My Application
OMB No. 0915-0146 Expiration Date: 06/30/2017

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Eligibility - Students to Service Loan Repayment Program

Eligibility
* required field

1. Are you a U.S. Citizen or U.S. National? *

Yes

2. Are you in your final year of medical, osteopathic, or dental school and planning to complete your last day of your course
work by May 31, 2017? *
Yes

3. Which of the following programs are you currently enrolled in? *
Accredited MD or DO Program

Accredited DDS or DMD Program

4. Have you applied to a Post Graduate Training Program? *
Yes

5. Do you have an existing service obligation? *

Yes

Will there be a conflict in fulfilling the NHSC obligation? *

Yes

Are you in a Reserve component of the Armed Forces, including the National Guard? *
Yes

6. Do you have a judgment lien against your property from a Federal debt? *
Yes

7. Are you currently in default on any Federal debt? *
Yes

8. Are you eligible to hold an appointment as a Commissioned Officer of the Public Health Service or a Federal civil service? *
Yes

Continue
OMB No. 0915-0146 Expiration Date: 06/30/2017

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General Information - Students to Service Loan Repayment Program

General Information
* required field

FULL NAME
First Name *

Jane

Last Name *

Smith

Middle Initial
Title

Select
Select

Suffix

Select
Select

HOME (PERMANENT) ADDRESS
Address Line 1 *
Address Line 2
Country *

Select
Select

State/Province/Region/Territory *

Select
Select

City *
Zip/Postal Code *

PREFERRED MAILING ADDRESS
My preferred mailing address is the same as my home address
Address Line 1 *
Address Line 2
Country *

Select
Select

State/Province/Region/Territory

Select
Select

*
City *
Zip/Postal Code *

PHONE
My preferred phone is an international number
Preferred Phone *
My alternate phone is an international number
Alternate Phone

EMAIL
Preferred *

https://testbcrs.hrsa.gov/beta/extranet/application/s2s/private/general-info.seam?cid=98[5/1/2017 5:34:37 PM]

bcrsrelaunch+MH1@gmail.com

General Information - Students to Service Loan Repayment Program

Alternate

SOCIAL SECURITY NUMBER
SSN *

Confirm SSN *

PLACE OF BIRTH
Country *

United States
United
States

State/Province/Region/Territory *

Select
Select

City *
Date of Birth *

DEMOGRAPHICS
Award selection will not be determined by this section
Gender

Male
Female

Ethnicity

Hispanic or Latino
Not Hispanic or Latino

Race

American Indian or Alaskan Native

You may multi-select
different race values.

Asian

Black or African-American

Native Hawaiian or Other Pacific Islander

White

Other

DISADVANTAGED BACKGROUND
Has your school ever certified you as having a disadvantaged background? (If yes, you will be required to upload a
supporting document). *
Yes

HOW DID YOU HEAR ABOUT S2S
How did you hear about the S2S

Select
Select

Program? *

Save & Continue
OMB No. 0915-0146 Expiration Date: 06/30/2017

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Letters of Recommendation - Students to Service Loan Repayment Program

Letters of Recommendation
* required field

All recommendations must be completed online. It is your
responsibility to ensure that both recommendations are submitted by
the application submission deadline date. You will not be able to submit your Students to
Service application until both
recommendations are completed. You
will be able to continue to the next page of the application once
both requests are sent
out. Additionally, you may cancel and
re-submit a request as long as the letter has not already been
completed by the
recommender. You will receive an email notification
once the recommender completes the process, however you will not be
able to see the completed letter of recommendation. The recommender
will not be able to upload letters of recommendation
after the
application deadline or once you submit your application.

PRECEPTOR LETTER OF RECOMMENDATION
This letter may be from a primary care preceptor or another individual who can discuss
the applicant’s interest in and
commitment to a career in primary care and service to
underserved populations and communities. The letter must have a
handwritten signature
and/or be on the institution's letterhead. If the requirements are not met the applicant
will be
deemed ineligible.
Status: Not Started
Recommender Title *

Select
Select
Mr.

First Name *
Last Name *
Email *

Request Recommendation

ADDITIONAL LETTER OF RECOMMENDATION
The second letter of recommendation should be from an individual who is familiar with the
applicant and who is aware of the
applicant’s academic, professional, community, and/or
civic activities, especially those related to primary care and
underserved communities.
A recommender can be a current or former employer, community leader, colleague, or anyone
who
has knowledge of the applicant’s interest and motivation in providing primary care in
underserved communities. The letter
must have a handwritten signature and/or be
on the institution's letterhead. If the requirements are not met the
applicant will be
deemed ineligible.
Status: Not Started
Recommender Title *

Select
Select
Mr.

First Name *
Last Name *
Email *

Request Recommendation

Save & Continue
OMB No. 0915-0146 Expiration Date: 06/30/2017

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Education - Students to Service Loan Repayment Program

Education
* required field

Please complete the fields below with your current school
information.

PROFESSIONAL HEALTH DISCIPLINE
Discipline *

Allopathic
Physician
Allopathic Physician

What specialty do you plan to pursue?

Select
Select

Note: the selection of a specialty does not
prohibit an applicant from selecting a different NHSC-approved
specialty at the time
of the residency match.

DEGREE
What Degree or certification will you receive upon

Select
Select

completion of your program? *

SCHOOL
Select the state where the school is located *

Select
Select

Select the name of the school *

Select
Select

If your school is not listed in the drop
down, please contact NHSC at NHSCSP@hrsa.gov with the subject
line "School Not
Found."
On what date did you begin your education at the
school identified above? *
What is the length of your program? *

Select
Select

What year in school are you currently? *

Select
Select

On what date will you graduate? *

Continue
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Education - Students to Service Loan Repayment Program

Education
* required field

Note: An additional question on Post Graduate Training is
displayed for dentists

Please complete the fields below with your current school
information.

PROFESSIONAL HEALTH DISCIPLINE
Discipline *

Dentist
Dentist

What specialty do you plan to pursue?

Select
Select

Osteopathic Physician

Geriatrics

Note: the selection of a specialty does not
prohibit an applicant from selecting a different NHSC-approved
specialty at the time
of the residency match.

DEGREE
What Degree or certification will you receive upon

Select
Select
DDS

completion of your program? *

SCHOOL
Select the state where the school is located *

Select
Select

Select the name of the school *

Select
Select

Alabama

Select
Select

What year in school are you currently? *

Select
Select

1 year

First

On what date will you graduate? *
Have you applied to a Post Graduate Training

Yes

Program? *

Continue
OMB No. 0915-0146 Expiration Date: 06/30/2017

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Loan Summary - Students to Service Loan Repayment Program

Loan Information
In this section, you will be required to add the loans that you
want approved for repayment under the National Health Service
Corps (NHSC)
Students to Service Loan Repayment Program.
To expedite this process, you may import your federal student
loan(s) from the U.S. Department of Education's National
Student Loan
Data System (NSLDS) directly into the online application. For loans
imported from the NSLDS, no supporting
documents are required.
To access your federal student loan(s) use the
"Access your Loans" button below. You will be directed to the
Department of
Education's Federal Student Aid login page and
required to log in using your Federal Student Aid ID (FSA ID).
If you have any
questions about your FSA ID, please visit:
https://www.nslds.ed.gov/npas/pub/faq.htm
After successfully logging in to FSA, you will be automatically directed
back to your application with your loans displayed
below. Once your loans have
been imported, please ensure all loans you wish to submit are listed.
You may also select the
'Return to Source' button from the FSA ID Login screen at any time.
For additional loans that are not covered in the NSLDS and may
be private education loans, you can still manually enter the
loans
along with supporting documents. Any loans that do not appear in
your NSLDS account must be added to your
application manually.
If you attempt to add a loan that you believe is NOT a federal
student loan(s), but receive an error
message, please check the
loan data and try again. It is possible that the loan is a
duplicate to one that you have added
electronically.
Important Note: If you experience any technical difficulties,
please contact the Customer Care Center at
1-800-221-9393
(TTY: 1-877-897-9910) Monday through Friday (except federal holidays)
from 8:00 a.m. to 8:00 p.m. ET or email us.
If you are
unable to resolve your technical difficulties or concerns in time
to submit your complete application prior to May 30, 2017, the
application deadline,
please enter your loans manually. The period for submitting applications will not
be extended due to
difficulties with submitting your loans.
To manually add loans, click the "Need Help?"
link to manually add loans you wish to submit for loan repayment.
When entering your loan information manually,
you must enter loan information and supporting documentation
for each
servicing lender that you wish to be considered for repayment.
The following documents will be required:
Account Statement (both private and federal) -
Most recent statement from your lender/servicer that has your name,
current loan balance and interest rate. This may be the official paper version,
or a printed web version, that is scanned,
uploaded, and not older than 30 days
from the date you will submit your application.
NSLDS Aid Summary Report (federal loans) -
Most recent summary report taken from your National Student Loan
Data Systems (NSLDS)
account. This may be the official paper version, or a printed web version, that is scanned
and
uploaded. Note: This is the summary report only, which lists your federal student loans
in one document and is available
at http://www.nslds.ed.gov

Disbursement Report or Promissory Note (non-federal loans) -
A copy of the document provided by your
lender/servicer that outlines the details of
your loan agreement, including your name, the date the loan was obtained,
the purpose of the loan, account numbers, and the loans included in a consolidation
(if applicable).
If you have a consolidated loan, you must enter in all of the information in the table.
All of the information must coincide with
the information in the loan documents. If
they do not coincide, the loan will be deemed ineligible.
You have not added any loans yet.

LOG INTO YOUR NATIONAL STUDENT LOAN DATA SYSTEM ACCOUNT
Access your Loans

NEED HELP?
Don't have a Federal Student Aid ID or want to enter loans manually?

Continue
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Loan Details - Students to Service Loan Repayment Program

Loan Details
* required field

Back to Loan Information
You have elected to add your qualifying education loans to your
application manually. This method is required for adding ALL
loans
that are NOT federal student loan(s). If you have elected to add your
federal student loan(s) using this method you must
not attempt to add
them using the electronic import method, or you will receive an error
message and put you at risk of missing
the application deadline.
Include all qualifying education loans, even if they exceed the
maximum award amount. Please exclude letters, special
characters
(i.e. $, %), and commas when entering outstanding loan balances and
interest rates. If you have multiple loans with
the same
servicer/lender, you must enter each loan separately.
To add your loans successfully and to ensure that your loans
have the best chance to qualify for repayment when reviewed,
you must
retrieve, scan and upload the current account statements from your
loan servicers and the Aid Summary Report from
your NSLDS online
account (federal student loan(s)) or a disbursement report for any
private loans, for each loan.
For each field completed below, the supporting documents must
verify the information you have entered.
Name of current servicing lender *

Select
Select

Loan account number *
Original date of the loan *

Original amount of the loan *
as of

Current balance (Principal & accrued Interest) *
Type of loan *

Select
Select

Is this loan in default? *

Yes

Is this Loan under Federal court judgment? *

Yes

Interest rate
Purpose of loan *
Is this a consolidated loan? *

Select
Select

Continue to Documents
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Supporting Documents - Students to Service Loan Repayment Program

Supporting Documents
Back to Loan Information

Please select the document you would like to upload from the "Browse" selection and then click "Upload." The loan
supporting documents are required in order to establish that this loan coincides with the education periods entered on the
Education section of the application.
You are required to upload the Account Statement for this loan ONLY. Additionally, you are required to upload either the
Aid Summary Report (for Federal loans) or the Disbursement Report (for non-Federal loans) for this loan ONLY. Uploading
supporting documents for different loans will slow down processing time. You may add additional loans on the Loan
Summary Page, once you save the current loan you have just added.
Please note: The following file types are not suitable for being uploaded: jpg, doc, xls & tif. Password protected files are not
acceptable and will disqualify the loan. Loan documents must be official and obtained directly from the lender/servicer.
Copies of website versions are acceptable.

UPLOADED DOCUMENTS
You have not uploaded any documents yet.

UPLOAD DOCUMENT
Account Statement
Disbursement Report

no file selected

Upload

Save
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Supporting Documents - Students to Service Loan Repayment Program

Supporting Documents
* required field

Select the document you would like to upload and then click "Upload". Once uploaded, documents will appear under the
"Uploaded Documents" section. You may download a blank form to the corresponding document by clicking the title of the
document in the
"Additional Documents" section below
Please upload PDF documents when possible to enhance processing time.
Documents cannot be larger than 5MB in
size. TIFF,
JPEG, PNG, and HTML are NOT acceptable file types. Multiple
documents uploaded in the incorrect
location may cause delays in
processing your application.
*Application Essay: Please discuss your commitment to pursue a career in primary health care and how you plan on
contributing to the mission of the NHSC in providing care to underserved communities.
Essays should be a maximum of two pages, with Times New Roman 12 font.
* National Board Scores: Dental students will be required to submit documentation verifying that
they have passed Part I of the
National Board Dental Examination.
Please Note: All information provided in the supporting documents and the online application must be consistent.
Applications with discrepancies will not be considered for an award.

ADDITIONAL DOCUMENTS
Authorization to Release Information
Verification of Good Standing Report
Verification of Disadvantaged Background

UPLOAD DOCUMENTS
Document Title

Document File

Status

Delete

Application essay document

TEST DOCUMENT PDF.pdf

Received

delete

Authorization to Release Information

Not Received

CV/Resume

Not Received

National Board Scores

Not Received

Proof of US Citizenship

Not Received

Unofficial Transcript

Not Received

Verification of Disadvantaged Background

Not Received

Verification of Good Standing Report

Not Received

no file selected

Upload

LOAN DOCUMENTS
Servicing Lender & Account #

Document Title

Document File

Status

Access Group 12345

Account Statement

TEST DOCUMENT PDF.pdf

Received

Access Group 12345

Disbursement Report

TEST DOCUMENT PDF.pdf

Received

Save & Continue
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Self Certification - Students to Service Loan Repayment Program

Self Certification
1. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, DISQUALIFICATION AND
RELATED MATTERS FORM:
Pursuant to 2 CFR 180.335 (2006) as implemented by 2 CFR 376.10 (2007), an applicant applying to enter into a covered
transaction (which includes an application to participate in the S2S LRP) is required to notify the Federal agency office if the
applicant knows that he or she:
Is presently debarred, suspended, excluded, or disqualified from participation in covered transactions by any Federal
agency or department;
Within the 3-year period preceding the application, has been convicted of, or had a civil judgment rendered against him or
her for any of the following offenses:
commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public
(Federal State, or local) transaction or a contract under a public transaction;
violation of Federal or State antitrust statutes; or
commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax
evasion, receiving stolen property, making false claims, or obstruction of justice;
Is presently indicted or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with the
commission of any of the offenses set forth above; or
Within a 3-year period preceding the application, has had any public transaction (Federal, State, or local) terminated for
cause or default.
I certify that the above statements do not apply to me. *

2. AUTHORIZATION FOR DISCLOSURE OF FINANCIAL INFORMATION:
Pursuant to the Rights to Financial Privacy Act of 1978 (RFPA) (12 USC 3404), having read the
statement of my RFPA
rights, I hereby authorize the government or financial institution named in item 1 and/or 9 on each Loan Details page to
release financial records relating to educational loans(s) identified on the Loan Details page to the S2S LRP for the purpose of
assessing and verifying the amount and eligibility of the educational loan for payment under the S2S LRP. This authorization is
valid for 3 months from the date of my signature, and may be revoked in writing at any time before my records are
disclosed. *

3. APG CERTIFICATION:
I certify that I have read and understand the terms to the 2017
NHSC S2S LRP Application and Program Guidance
(APG) *

Continue
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Review & Submit - Students to Service Loan Repayment Program

Review & Submit
Please review each of the sections listed below prior to
submitting your application.
Please Note: Do not submit your application until you are certain it is complete. You will not be able to edit your submitted
application after the application deadline. After submission, your final application will be available to download, and print in
PDF format on the Home page. All supporting documents will be listed on the Home page. All applications must be submitted
by May 30, 2017 at 12:00 AM EDT.
Page Name

Status

Eligibility

Complete

General Information

Complete

Education

Complete

Letters of Recommendation

In Progress

Loans

Complete

Supporting Documents

Complete

Self-Certifications

Complete

Review & Submit

In Progress

SUBMIT YOUR APPLICATION:
I certify that the information given in this application, including supporting documentation uploaded into this application, is
accurate and complete to the best of my knowledge and belief. I understand that it may be investigated and that any willfully
false representation is sufficient cause for rejection of this application, or, if awarded loan repayment, that I am liable for
repayment of all awarded funds and further that any false statement herein may be punished as a felony under U.S. Code,
Title 18, Section 21001 and subject me to civil penalties under the Program Fraud Civil Remedies Act of 1986 (45 CFR 79)"
Password *

submit
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Students to Service Loan Repayment Program

National Health Service Corps Students to Service Loan
Repayment Program
Hello Jane,
You have submitted your 2017
National Health Service Corps Students to Service Loan Repayment Program online application!
Your Application Status is: Submitted
Application ID: 387960
VIEW YOUR SUBMITTED APPLICATION
To edit your application or upload additional documentation, you
may do so prior to the application deadline, May 30, 2017 at
12:00 AM EDT,
by clicking EDIT YOUR APPLICATION. If the
deadline has passed, the contents and status of your application
is
final and cannot be edited by you or the NHSC.
Important Note: By selecting the "Edit Your
Application" button, you will reset the application and your
application status reverts
back to "In Progress" and must repeat
the process to resubmit your application prior
to the application deadline May 30, 2017 at
12:00 AM EDT,
even if changes were not made. If you do not resubmit your
application by the application deadline your
application cannot
be reviewed. If you would like to view a read-only copy of your
full application, without the need to resubmit,
please click the
VIEW YOUR SUBMITTED APPLICATION button
at the top of this page.
Application
Edit Edit
Application

GENERAL SUPPORTING DOCUMENTS
Document Title

Document Name

Status

Application essay document

TEST DOCUMENT PDF.pdf

Received

Authorization to Release Information

TEST DOCUMENT PDF.pdf

Received

CV/Resume

TEST DOCUMENT PDF.pdf

Received

National Board Scores

TEST DOCUMENT PDF.pdf

Received

Proof of US Citizenship

TEST DOCUMENT PDF.pdf

Received

Unofficial Transcript

TEST DOCUMENT PDF.pdf

Received

Verification of Disadvantaged Background

TEST DOCUMENT PDF.pdf

Received

Verification of Good Standing Report

TEST DOCUMENT PDF.pdf

Received

LOAN SUPPORTING DOCUMENTS
Servicing Lender & Account #

Document Title

Document File

Status

Access Group 12345

Account Statement

TEST DOCUMENT PDF.pdf

Received

Access Group 12345

Disbursement Report

TEST DOCUMENT PDF.pdf

Received

https://testbcrs.hrsa.gov/beta/extranet/application/s2s/private/landing.seam?cid=98[5/1/2017 6:08:26 PM]

Students to Service Loan Repayment Program

National Health Service Corps Students to Service Loan
Repayment Program
Congratulations! Your application has been identified as
"eligible" for a 2017 National Health Service
Corps (NHSC) Students
to Service (S2S) Loan
Repayment Program (LRP) award. This is not a guarantee of an award.
To confirm your intent to accept
this offer, please complete the
following steps by the end of the day on November 08, 2016.
Your overall Application Status is: Offered Award
VIEW YOUR SUBMITTED APPLICATION

Step 1

Please review the following information. The maximum
award amount is $120,000. If your qualifying debt
exceeds the
maximum, you will be funded $120,000. If any information is
incorrect, please contact NHSC at 1800-435-6464.
Verified Loan
Account / Loan Number

Loan Type

Servicer

Current
Balance

Eligible
Amount

1234567

Manual

Access Group

$100,000.00

Total Approved For

$100,000.00 Projected Award

Repayment:

Step 2

$100,000.00

Disbursement:

Please review the program guidelines and service requirements, as outlined in the 2017 S2S
LRP Program
Guidance

. Confirm or decline your intent to participate in S2S LRP below.

I wish to be considered for the 2017 S2S LRP Award.
I am no longer interested in receiving the 2017 S2S LRP Award. I understand that I will no longer be
considered for an S2S LRP award.

Step 3

Please enter your banking information. This is used to
deposit your loan repayment funds as a participant of
S2S LRP.
This should be the account you wish S2S LRP to deposit funds in.
Bank Name *
Account Type *
Routing Number *

Re-enter Routing Number *
Account Number *

Re-enter Account Number *

https://testbcrs.hrsa.gov/extranet/application/s2s/private/landing.seam?cid=2664[11/7/2016 2:58:07 PM]

Checking

Students to Service Loan Repayment Program

Continue

https://testbcrs.hrsa.gov/extranet/application/s2s/private/landing.seam?cid=2664[11/7/2016 2:58:07 PM]

Sign Your Electronic Contract - Students to Service Loan Repayment Program

Sign your Electronic Contract
* required field

Note: an additional question on
residency is displayed for dentists

This contract is not binding until countersigned by the
Secretary of the Department of Health and Human Services or
his/her
designee.
View a printable version of the NHSC S2S
contract

LEGAL NOTICE
Please read through the entire contract. Once you have
finished, you will need to certify that your e-signature is
legally
binding. If you would like to print this contract, please
select the link above to view and print the NHSC S2S LRP Contract.

CONTRACT

RESIDENCY
Please confirm whether you have applied to a Post Graduate Training Program.
Yes

CERTIFICATION
I certify that: I have read the above contract in its entirety and my electronic signature on this contract is intended to be the
legally binding equivalent of my handwritten signature.
Yes

Sign and Submit

https://testbcrs.hrsa.gov/alpha/extranet/application/s2s/private/coi-accept.seam?cid=20[5/8/2017 5:10:22 PM]

Sign Your Electronic Contract - Students to Service Loan Repayment Program

Sign your Electronic Contract
* required field

This contract is not binding until countersigned by the
Secretary of the Department of Health and Human Services or
his/her
designee.
View a printable version of the NHSC S2S
contract

CONTRACT

ENTER SIGNATURE INFORMATION
SSN *

Confirm SSN *
What is your favorite pet's name? *

Password *

Sign and Submit

https://testbcrs.hrsa.gov/extranet/application/s2s/private/coi-accept.seam?cid=2506[11/8/2016 12:30:24 PM]

Decline Offer of the S2S LRP Award - Students to Service Loan Repayment Program

Decline Offer of the S2S LRP Award
* required field
Back
You have indicated that you are no longer interested in
receiving the National Health Service Corps (NHSC) Students to
Service
(S2S) Loan Repayment Program (LRP) award. If this is not correct you may go
back and change your answer.
Please indicate your reason for declining the
NHSC S2S LRP award. *

Decline

https://testbcrs.hrsa.gov/alpha/extranet/application/s2s/private/coi-decline.seam?cid=20[5/8/2017 5:10:49 PM]

Students to Service Loan Repayment Program

National Health Service Corps Students to Service Loan
Repayment Program
Hello Jane,
You have confirmed your intent to accept the
2017 National Health Service Corps (NHSC)
Students to Service (S2S) Loan
Repayment Program (LRP)
award. You are not guaranteed an award at this time. We will
review the information you submitted
as part of your acceptance
to ensure completeness and accuracy.
Please wait for the NHSC S2S LRP to contact
you regarding your award.
The NHSC uses your primary email address to communicate
application status changes and requests for additional
information regarding your application. Please ensure that we
always have the most accurate contact information.
All awards will be made by January 31,
2017.
Your overall application status is: Accepted
Award - Under Final Review
Your application ID is: 339039
VIEW YOUR SUBMITTED APPLICATION
Your National Health Service Corps (NHSC) Students to Service Program signed contract

GENERAL SUPPORTING DOCUMENTS
Document Title

Document Name

Status

Application essay document

TEST DOCUMENT PDF.pdf

Received

Authorization to Release Information

TEST DOCUMENT PDF.pdf

Received

CV/Resume

TEST DOCUMENT PDF.pdf

Received

National Board Scores

TEST DOCUMENT PDF.pdf

Received

Proof of US Citizenship

TEST DOCUMENT PDF.pdf

Received

Uniformed Service/Existing Service Document

TEST DOCUMENT PDF.pdf

Received

Unofficial Transcript

TEST DOCUMENT PDF.pdf

Received

Verification of Disadvantaged Background

TEST DOCUMENT PDF.pdf

Received

Verification of Good Standing Report

TEST DOCUMENT PDF.pdf

Received

LOAN SUPPORTING DOCUMENTS
Servicing Lender & Account #

Document Title

Document File

Status

Access Group 1234567

Account Statement

TEST DOCUMENT PDF.pdf

Received

Access Group 1234567

Disbursement Report

TEST DOCUMENT PDF.pdf

Received

https://testbcrs.hrsa.gov/extranet/application/s2s/private/landing.seam?cid=2506[11/8/2016 12:33:06 PM]

File Type	application/pdf
File Modified	2017-05-15
File Created	2017-05-01