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Apply to HCAI Funding
Application {% if request.params.id %} {% assign applvn = entities.eapp_applvn[request.params.id] %}{% endif %}{{ applvn.eapp_name }} – Allied Healthcare Loan Repayment Program
Application – Allied Healthcare Loan Repayment Program
General Information
Program<span style="color:red"> *</span>
*
Applicant Name
*
*
Are you currently employed by a qualifying CMSP-Contracted Provider Facility?
*
*
Are you a military veteran with an honorable discharge?
*
*
Are you a military veteran with an honorable discharge
No
Are you a military veteran with an honorable discharge
Yes
Are you a prior or current Office of Health Workforce Development (OHWD) or Health Care Access and Information (HCAI) Awardee?
*
*
Are you a prior or current Office of Statewide Health Planning and Development (OSHPD) or Health Care Access and Information (HCAI) Awardee is a required field.
*
No
Are you a prior or current Office of Statewide Health Planning and Development (OSHPD) or Health Care Access and Information (HCAI) Awardee is a required field.
*
Yes
What was your previous Grant Agreement Number?
*
*
As defined by the Scholarship for Disadvantaged Students program, have you been identified as having a disadvantaged background based on environmental and/or economic factors, or did you receive a federal Exception Financial Need Scholarship?
*
*
disadvantaged or receive financial need
No
disadvantaged or receive financial need
Yes
Do you have an existing service obligation?
*
*
Existing Service Obligation
No
Existing Service Obligation
Yes
Entity Name
*
Start Date of Obligation
*
End Date of Obligation
*
Have you ever participated in a health care career pathway program?
*
*
Have you ever participated in a health care career pathway program?
No
Have you ever participated in a health care career pathway program?
Yes
Have you ever participated in a health care career pathway program?
Don't Know
Do you currently work or volunteer for a State of California entity?
*
Do you currently work or volunteer for CA Entity?
No
Do you currently work or volunteer for CA Entity?
Yes
Have you ever worked or volunteered for a State of California entity?
*
Have you ever worked or volunteered for CA entity
No
Have you ever worked or volunteered for CA entity
Yes
*
