10-255a Specialty Education Loan Repayment Program (SELRP) - App

OMB Control No: 2900-0879
Estimated Burden: 40 min
Expiration Date: XXX XX, 2023

APPLICATION - SPECIALTY EDUCATION LOAN
REPAYMENT PROGRAM

The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Therefore, we may not conduct or
sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete
this form will average 40 minutes. This includes the time it will take to follow instructions, gather the necessary facts, and fill out the form. Participation in this program is voluntary, but
failure to provide complete and accurate responses on the application may impact your selection to participate in and receive the benefits of the program.
Privacy Act Notice: The VA is asking you to provide the information on this form under the authority of 38 U.S.C. 7502 and 7602 in order for VA to determine your eligibility to receive
an education debt reduction payment award. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information for:
civil or criminal law enforcement; congressional communications; the collection of money owed to the United States; litigation in which the United States is a party or has interest; the
administration of VA training, scholarship and education reduction programs, including verification of your eligibility to participate; and personnel administration. You do not have to
provide this information to VA; but if you do not, VA may be unable to process your request for consideration in this program. If you give VA your social security number, VA will use it
to obtain information relevant to determining whether to grant a loan repayment program award and to administer your education loan repayment, if awarded. It also may be used for other
purposes authorized or required by law.

INSTRUCTIONS: Please furnish all information in sufficient detail to enable the Department of Veterans Affairs (VA) to determine your
eligibility and ranking for selection to receive a loan repayment award from VA. Type or print in ink. If additional space is required, use the space
in Section V.

PRELIMINARY ELIGIBILITY QUESTIONS
1. Are you currently enrolled in a medical residency program? If no, move on to Question 3.

Yes

No

Yes

No

2. If you responded “Yes” to question 1, do you have at least two years remaining in your program?

Yes

No

3. If you responded “No” to question 1, have you graduated from an accredited medical or osteopathic school AND
matched to an accredited residency program?

Yes

No

4. Are you certified to practice within one of the clinical specialties listed in the program guidance?

Yes

No

5. Are you a citizen of the United States?

Yes

No

6. Are you able to complete the required full-time VA employment obligation after graduation and required licensure/
certification? This will require relocation at your expense if there is not a suitable vacancy or you are not selected for
employment at a VA facility nearby.

Yes

No

7. Do you owe a service obligation to any other entity to perform service after you complete your residency program?

Yes

No

Yes

No

Yes

No

A. List Residency Program and Clinical Specialty:
B. Is your residency program located in a rural area; operated by Indian tribes, tribal organization or the Indian Health
Services?

8. Are you currently enrolled or receiving loan repayment, reimbursement or other assistance for loans? (Excluding the

Public Service Loan Forgiveness program.)

9. Are you delinquent on payment of a federal debt? This includes delinquent taxes, audit disallowances, guaranteed or
direct student loans, Federal Housing Administration (FHA) or VA mortgages, and other miscellaneous administrative
debts.

If you answered “yes” to questions 7,8, or 9, you are NOT eligible for this program and should not submit an application.

SUMMARY OF THE COMPLETE APPLICATION PACKAGE REQUIREMENTS
The following items constitute a complete application package. It is the responsibility of the applicant to ensure that the application package is
complete, accurate and submitted by the deadline. Questions regarding application materials should be directed to the point of contact listed in the
program materials. Incomplete applications will not be reviewed.
1. SELRP Application Form (VA Form 10-XXX) and Supporting Documentation
A. Resume
B. Academic Transcripts from Med School (Unofficial transcript acceptable)
C. Medical School Diploma or Transcript Indicating Degree Conferred (copy)
D. Recommendation Letters
i. From academic program where you will be or where you are currently enrolled and
ii. From a person who has known you for a minimum of two year
E. National Student Loan Data System Verification Information or copy of loan details
F. Loan Verification Forms
2. OF-306
3. VA Form 10-2850
VA FORM
NOV 2020

10-255a

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OMB Control No: 2900-0879
Estimated Burden: 40 min
Expiration Date: XXX XX, 2023

APPLICATION FOR SPECIALTY EDUCATION
LOAN REPAYMENT PROGRAM
SECTION I – APPLICANT INFORMATION AND PREFERENCES
APPLICANT NAME (Last, First, MI):

APPLICANT SSN:

PERSONAL EMAIL:

PRESENT ADDRESS

CLINICAL SPECIALTY

ESTIMATED OUTSTANDING EDUCATION LOAN DEBT (Final amount will

be determined following review of applicant's qualifying student loan debt):

SELECT TOP PREFERRED LOCATIONS FOR EMPLOYMENT (Selectees preferences will be considered; however final placement will be

determined by the VA.):

SITE 1

SITE 6

SITE 2

SITE 7

SITE 3

SITE 8

SITE 4

SITE 9

SITE 5

SITE 10

SECTION II – PERSONAL STATEMENT
PLEASE INCLUDE WHY YOU WANT TO WORK FOR THE VETERANS HEALTH ADMINISTRATION, YOUR CLINICAL AREAS OF INTEREST
AND YOUR SHORT-RANGE (less than five years) AND LONG-RANGE (between five and ten years) GOALS?

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SECTION III – REQUIRED AND SUPPLEMENTAL INFORMATION
Use this section to annotate the attachments required to complete your application. Be sure to include all attachments included when submitted
the application.
REQUIRED:
SUPPLEMENTAL (please list below):
RESUME
TRANSCRIPTS FROM MED SCHOOL
LETTER OF REFERENCE 1
LETTER OF REFERENCE 2
NATIONAL STUDENT LOAN DATA SYSTEM
LOAN VERIFICATION FORMS
ENTER EXPLANATIONS TO PRIOR QUESTIONS AND SUPPLEMENTAL INFORMATION. (Be sure to indicate the corresponding question

number on the form to which the comment refers.)

SELRP Program Requirements:
a. I am aware of the required service obligation to work in a VA health care facility in a full-time position for which I will be prepared after
completing the education program supported by the SELRP. This will require relocation at my expense if there is not a suitable vacancy or if I
am not selected for employment at a nearby VA facility.
b. I am aware of the penalties as described in the program agreement if I do not complete the education program for which I am requesting
SELRP or if I do not complete the required service obligation.
SECTION IV – AUTHENTICATION
The Family Education Rights and Privacy Act of 1974 (FERPA), as amended, affords you certain rights regarding your education records.
FERPA generally prohibits schools from releasing education records or certain information contained in such records, such as your grades, billing
and payment records, financial aid awards, and other student record information, to third parties. This consent to release records to the VA applies
to such records that may otherwise be protected under FERPA. Institutions may, pursuant to Consolidated Appropriations Act, 2018 [Public Law
115-141] and with explicit written consent from the student, share Free Application for Federal Student Aid (FAFSA) information with a
scholarship granting organization or tribal organization. The recipient of records under this authorization may not re-disclose information from
student records without the prior written consent of the student or as permitted by law.
In order to determine eligibility, award, and administer the Specialty Education Loan Repayment Program,) the Department of Veterans Affairs
(VA) requires information to be released by your school to VA representatives. This form authorizes the education institutions listed to release
this information to VA representatives. List all schools for which loan repayment is sought (e.g., one per transcript):
SCHOOL NAME:

SCHOOL NAME:

SCHOOL NAME:

SCHOOL NAME:

I certify that the information given in this application is accurate and complete to the best of my knowledge and belief. I understand that any
information I have provided may be investigated and that any false representation is sufficient cause for rejection of this application or, if granted
and award, that I am liable for repayment of all awarded funds and, further, that any false statement herein may be punishable under U.S. Code,
Title 18, Section 1001. I understand that decisions on awards will be final.
APPLICANT NAME (print or type):

APPLICANT SIGNATURE:

DATE:

All material submitted becomes the property of the Federal Government and will not be returned.
Read the accompanying Applicant Information Bulletin before completing this form.

VA FORM
NOV 2020

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