Form 10-255d Specialty Education Loan Repayment Program (SELRP) - Mob

OMB Control No: 2900-0879
Estimated Burden: 10 min
Expiration Date: XXX XX, 2023

Specialty Education Loan Repayment Program (SELRP)
Mobility Agreement
PRIVACY ACT NOTICE

The VA is asking you to provide the information on this form under the authority of 38 U.S.C. §7693 (SELRP) in order for
VA to determine the applicant's eligibility to receive a scholarship 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 and scholarship programs, including verification of
the applicant's 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 the applicant's request for a scholarship. If you give VA a social security
number, VA will use it to obtain information relevant to determining whether to grant a scholarship, and to administer the
applicant's scholarship, if awarded. It also may be used for other purposes authorized or required by law.
The purpose of the Specialty Education Loan Repayment Program is to assist, through the establishment of an incentive
program for certain individuals employed in the Veterans Health Administration, in meeting the staffing needs of the
Veterans Health Administration for physicians in medical specialties for which the Secretary determines recruitment or
retention of qualified personnel is difficult.
SSN (Last 4 Only):

Name of Applicant (Last, First, MI):

Initial Here

I understand that while my preferences will be considered to the extent possible, my initial
assignment after graduation and completion of my licensure/certification, will be made based on
the needs of the Veterans Health Administration and I may be required to accept assignment at
any VHA facility where my services are needed.

Initial Here

I agree to relocate, if necessary, at my own expense to complete my service obligation period in
accordance with Sections B.1 of my SELRP Participant Agreement.

Initial Here

I understand if my initial assignment is not offered at my facility of choice, relocation benefits
will not be paid by the Scholarships and Clinical Education Office.

Initial Here

I understand, if I refuse to relocate for my initial assignment I am subject to the provisions of
Section C.2. of my SELRP Participant Agreement.

Certification of Accuracy
I acknowledge that by accepting this scholarship, I hereby agree to abide by the terms of this Mobility Agreement.
(Inaccurate data may cause the student to lose funding.)

Name (Print)

Phone Number (include area code)
VA FORM
FEB 2020

10-255d

Signature of Program Participant

Date

E-mail Address
PAGE 1 of 1