IHS Loan Repayment Program Application Handbook

Indian Health Service Loan Repayment Program
APPLIcAtIon HAndbook
Section 2: Educational and Professional Background
(Educational and Professional Background for Graduates Only)
FORM APPROVED
OMB Approval No. 0917-0014
Exp. Date 02/29/2012
1. Name of Professional School __________________________________________________________________________________
School Address_______________________________________________________________________________________________
Number Street Apt. or Room #
Graduate year and degree obtained_______________________________________________________________________________
2. Have you completed a residency or graduate program? Yes No
(MD, DO, DDS, PedNP, PA, etc.)
2a. Year residency or program was/will be completed_____________________________________________________________
Residency or Program Name __________________________________________________________________________________
Address___________________________________________________________________________________________________
Director of Residency/Program ________________________________________________________________________________
Name Phone
2b. Specialty (for physicians only) _______________________________________________________________________________
Board Certified Board Eligible
Year re-certified (if applicable)____________________
Sub-specialty (if applicable) ______________________
3. If applicable, please list all professional training location(s) separately.
a. Program Name_____________________________________________________________________________________________
Address ____________________________________________________________________________________________________
Program Director’s Name______________________________________________ Phone ___________________________________
b. Program Name_____________________________________________________________________________________________
Address ____________________________________________________________________________________________________
Program Director’s Name______________________________________________ Phone ___________________________________
c. Program Name _____________________________________________________________________________________________
Address ____________________________________________________________________________________________________
Program Director’s Name______________________________________________ Phone ___________________________________
4. If applicable, describe your practice experience over the last five years.
(Include location, nature of population served, number of specialties in the practice, hospital affiliations and allocation of clinical
practice time to FP/GP, INT, OB/GYN, PED, PSYCH, ER. If you need more space, please use continuation sheet, type your name and SSN
at the top of each page, and attach to your application.)
_____________________________________________________________________________________________________________
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