Are you currently employed by a CMSP Facility?*

Are you a military veteran with an honorable discharge?*

Are you a prior or current Office of Health Workforce Development (OHWD) or Health Care Access and Information (HCAI) Awardee?

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?*

Do you owe an existing service obligation?*

Have you ever participated in a health care career pathway program?*

Do you currently work or volunteer for a State of California entity?*

Have you ever worked or volunteered for a State of California entity?*

Race*

Please provide one unique contact. This should be a person not living with you (preferably relatives) that will know how to reach you should we need to contact you.

Please provide one unique contact. This should be a person not living with you (preferably relatives) that will know how to reach you should we need to contact you.

Please provide the name and address of the high school you graduated from or the home address if you were homeschooled or received a GED. Click on the "Not Applicable" checkbox if you did not receive a high school diploma or GED within the United States.

High School Name*

Are you the first member of your family to attend college?*

Highest level of degree obtained*

College/University Name*

Where did you complete college/university?

Date of Graduation*

Do you have a current and unrestricted professional license or registration to practice your profession with a CA board/committee or the American Registry of Diagnostic Medical Sonography?*

National Provider Identifier (NPI)

How many years of experience do you have working or training in HPSAs?*

Enter your current health-related work experience only. You must be working in a qualified facility at the time Grant Agreements are executed. Use the Add a Current/Future Employer button to enter each separate employer. Please make sure to save your Employment Verification Form (EVF) with the following prefix: EVF_ before uploading it at the end of the application.
-You must have at least one current/future employer.
-You must have at least a total of 32 Direct Patient Care hours per week.

Instructions:

Please provide information from the last two years of federal tax returns. If you did not file a federal tax return and are listed as a dependent on someone else's tax returns, you must provide your parent or guardian’s information.

Explanation:*

Use the spaces provided to answer the following question in complete detail, being as descriptive and as specific as possible. Personal statements that lack detail may not receive full points. Each answer should be unique to the question and answers should not be duplicated. Duplicated answers will be scored as zero (0). Please complete all questions on each page before moving on to the next page.

Describe how your family and employment background, education, training, and life experiences have influenced your decision to pursue a health professional career.*

Describe how your family and employment background, education, training, and life experiences have influenced your commitment to working in a underserved area.*

Have you lived in an underserved or disadvantaged community? If so, please describe your experiences. If not, describe how you can relate to a community that is underserved or disadvantaged.*

Describe your career goals in relation to your current employment.*

Give a specific example of how your professional and/or educational experiences have contributed to gaining an understanding of the cultural and linguistic needs of the medically underserved community.*

Why would you like to participate in this loan repayment program?

Professional License/Registration/Certification

Proof of Honorable Discharge

Employment Verification Form(s) (EVF)

Lender Statements

Conflict of Interest Letter

Certification

I certify that all information in this application is true and accurate to the best of my knowledge. I authorize the Department of Health Care Access and Information (HCAI) to verify any information submitted as part of this application. I understand that falsification of information contained in my application will disqualify my application. I understand that if falsification is discovered after I have been awarded or if I breach my contract, I will be required to repay funds awarded, plus interest and administrative fees. I understand that once submitted, my application and supporting documents become the property of HCAI.

I understand that, if awarded the Loan Repayment, I am agreeing to the below terms:

• Return all correspondence in a timely manner
• Sign a grant agreement. I would be entering into a signed, grant agreement with the Department of Health Care Access and Information (HCAI)
• When requested, submit an Employment Verification Form (EVF) for each current employer
• When requested, submit Progress Reports, signed by my supervisor(s) to verify that I am working and meeting the program requirements
• Provide direct patient care (minimum of 32 hours per week)
• Maintain employment at a qualified facility for a period of twelve (12) months
• Notify HCAI of any changes to my address, email, phone number, employment, and any leave of absence from work, within 7 days
• Not accept any other awards with other entities, including other HCAI programs which require me to fulfill a contract that overlaps with this service obligation
• Subject to repay funds received, with interest, if I do not comply with the terms of the grant agreement