0917-0028 General Applicant Information

IHS Loan Repayment Application - General Applicant Information

U.S. Department of Health and Human Services

www.hhs.gov
A - Z Index: A B C D E F G H I J K L M N O P Q R S T U V W X Y

Z #

Search ihs.gov
IHS Home

Give Us Feedback

LRP Home
Apply Now

General Applicant Information   Educational and Professional Background   Affidavit/Sample LRP    Finish

  Required Documents
  Complete Your Form

Indian Health Careers

General Applicant Information

Form Approved, OMB Approval No. 0917-0014, Expiration Date: 07/31/15

LRP Basics

The first section of the application covers general applicant information, including personal data, education information and details of existing service
obligations.

Policies
and Procedures 

For security reasons, your application session will timeout after 30 minutes of inactivity . If your application times out, any progress you've made
on your form will be lost. Please have any application materials (e.g. references, financial information) prepared ahead of time.

Site Scores

*indicates required field

Resources
Name
FAQs
Contact the LRP Office

Prefix:   

 *First:

*SSN:

*

Middle:

(xxx-xx-xxxx)      *Sex:

 *Last:
   *Date of Birth

 Suffix:
(mm/dd/yyyy) Help

Home Address
*Street:
*City:

   *State:

XX

   *Zip Code:

Work/School Address
Street:
   City:

   State:

XX

   Zip Code:

Phone and Email
Home Phone:  (

)

-

ext:

Work/School Phone:  (

)

-

ext:

*Email:
Are you currently employed with IHS?
Your answer indicated that you are not currently employed with the IHS.
Is your current employment with: (If you check any, you must submit employment verification with your application):  Help
A program conducted under a contract entered into under the Indian Self-Determination Act
A program assisted under Title V of the IHCIA
A Buy Indian Act organization
Are you an American Indian or Alaska Native?
Your answer indicated that you are not an American Indian or Alaska Native.
Have you ever received an IHS Health Professions (Section 104) Scholarship?
Your answer indicated that you have not received an IHS Health Professions (Section 104) Scholarship.
Discipline:

   Specialty:                                               

https://www.ihs.gov/loanrepayment/lrpOnlineApp/index.cfm?module=applicant_info[4/2/2015 3:19:27 PM]

IHS Loan Repayment Application - General Applicant Information

License/Registration/Cert?:
Do you have an existing service obligation?
You indicated that you do not have an existing service obligation.
Date you will be available to begin practice under the LRP

(mm/dd/yyyy)  Help

Continue

Estimated Average Burden Time to Complete the Application Form: Public reporting burden for this collection of information is estimated to vary from 60 to 120 minutes per response with an average
of 90 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Indian Health Service, Reports Clearance Officer, Attn: PRA
(0917-0014), 12300 Twinbrook Parkway, Suite 450, Rockville, MD 20852. Do not mail completed forms to the above address.

This website may require you to download plug-ins to view all content.
  Accessibility · Disclaimer · FAQs · Website Privacy Policy · Plain Writing Act · Freedom of Information Act · HIPAA · No Fear · Glossary · Contact

Indian Health Service (HQ) - The Reyes Building, 801 Thompson Avenue, Ste. 400 - Rockville, MD 20852

https://www.ihs.gov/loanrepayment/lrpOnlineApp/index.cfm?module=applicant_info[4/2/2015 3:19:27 PM]