Read through the Frequently Asked Questions - Frequently Asked Questions before completing this application or submitting questions regarding these programs.
Note: Once you begin to fill out this form, a record is created. Please fill it out in one setting or use the "returning" button in the top right hand corner if you need to come back later and complete your application. Email DHHS.LoanRepaymentPrgMgr@nebraska.gov if you need assistance with the access code, but DO NOT CREATE MULTIPLE RECORDS.
All fields are required unless otherwise specified.
First Name:
* must provide value
Last Name:
* must provide value
Date of Birth:
* must provide value
Today M-D-Y
Email Address (contract will be sent to this address):
* must provide value
Phone Number:
* must provide value
Address:
* must provide value
City:
* must provide value
State:
* must provide value
Zip Code:
* must provide value
American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other
Hispanic/Latino Non-Hispanic/Non-Latino Other
Female Male Other
Personal Information:
First Name:
Middle Name:
Last Name:
Maiden Name:
Date of Birth:
Contact Information:
Email Address:
(contract will be sent to this address)
Phone Number: Address: City: State: Zip Code:
Demographics are collected for federal reporting purposes and are optional:
National Practitioner Identifier Number (optional):
Profession:
* must provide value
MD/DO DDS/DMD Dental Hygienist Physician Assistant Nurse Practitioner Psychologist Licensed Mental Health Professional Masters Level Alcohol and Drug Abuse Pharmacist Occupational Therapist Physical Therapist Registered Nurse (Bachelor's level or higher) Masters Level Licensed Clinical Social Worker (LCSW) Masters Level Marriage and Family Therapist (MFT)
Specialty:
* must provide value
Family Practice General Internal Medicine General Pediatrics Obstetrics/Gynecology General Surgery Psychiatry Child and Adolescent Psychiatry
Specialty:
* must provide value
General Dentistry Pediatric Dentistry Oral Surgery
Are you currently fully licensed? (ie. no longer in residency, provisionally licensed, etc.)
* must provide value
Yes
No
License Number:
* must provide value
Enter date you expect to be fully licensed (you can apply up to 18 months before you are fully licensed):
* must provide value
Today M-D-Y
Type of Degree Received/Expected (MD, PA, etc.):
* must provide value
Date Degree Received/Expected:
* must provide value
Today M-D-Y
Have you completed residency and/or training?
* must provide value
Yes
No
When did you complete OR when do you expect to complete your residency and/or training?
* must provide value
Today M-D-Y
How many practice sites will you be working at?
* must provide value
1 2 3 4
Site 1 Name of Facility:
* must provide value
Site 2 Name of Facility:
* must provide value
Site 3 Name of Facility:
* must provide value
Site 4 Name of Facility:
* must provide value
Site 1 Address:
* must provide value
Site 2 Address:
* must provide value
Site 3 Address:
* must provide value
Site 4 Address:
* must provide value
Site 1 City:
* must provide value
Abie Adams Ainsworth Albion Alda Alexandria Allen Alliance Alma Alvo Amelia Ames Amherst Angora Anselmo Ansley Arapahoe Arcadia Archer Arlington Arnold Arthur Ashby Ashland Ashton Atkinson Atlanta Auburn Aurora Avoca Axtell Ayr Bancroft Barneston Bartlett Bartley Bassett Battle Creek Bayard Beatrice Beaver City Beaver Crossing Bee Beemer Belden Belgrade Bellevue Bellwood Belvidere Benedict Benkelman Bennet Bennington Bertrand Big Springs Bingham Bladen Blair Bloomfield Bloomington Blue Hill Blue Springs Boelus Boys Town Bradshaw Brady Brainard Brewster Bridgeport Bristow Broadwater Brock Broken Bow Brownville Brule Bruning Bruno Brunswick Burchard Burr Burwell Bushnell Butte Byron Cairo Callaway Cambridge Campbell Carleton Carroll Cedar Bluffs Cedar Creek Cedar Rapids Center Central City Ceresco Chadron Chambers Champion Chapman Chappell Chester Clarks Clarkson Clatonia Clay Center Clearwater Cody Coleridge Colon Columbus Comstock Concord Cook Cordova Cortland Cozad Crab Orchard Craig Crawford Creighton Creston Crete Crofton Crookston Culbertson Curtis Dakota City Dalton Danbury Dannebrog Davenport Davey David City Dawson Daykin De Witt Decatur Denton Deshler Deweese Dickens Diller Dix Dixon Dodge Doniphan Dorchester Douglas Du Bois Dunbar Duncan Dunning Dwight Eagle Eddyville Edgar Edison Elba Elgin Elk Creek Elkhorn Ellsworth Elm Creek Elmwood Elsie Elsmere Elwood Elyria Emerson Emmet Enders Endicott Ericson Eustis Ewing Exeter Fairbury Fairfield Fairmont Falls City Farnam Farwell Filley Firth Fordyce Fort Calhoun Franklin Fremont Friend Fullerton Funk Garland Geneva Genoa Gering Gibbon Gilead Giltner Glenvil Goehner Gordon Gothenburg Grafton Grand Island Grant Greeley Greenwood Gresham Gretna Guide Rock Gurley Hadar, Hadar Haigler Hallam Halsey Hampton Hardy Harrisburg Harrison Hartington Harvard Hastings Hay Springs Hayes Center Hazard Heartwell Hebron Hemingford Henderson Hendley Herman Hershey Hickman Hildreth Holbrook Holdrege, Holdrege Holstein Homer Hooper Hordville Hoskins Howells Hubbard Hubbell Humboldt Humphrey Hyannis Imperial Inavale Indianola Inland Inman Ithaca Jackson Jansen Johnson Johnstown Julian Juniata Kearney Kenesaw Kennard Keystone Kilgore Kimball La Vista Lakeside Laurel Lawrence Lebanon Leigh Lemoyne Lewellen Lewiston Lexington Liberty Lincoln Lindsay Linwood Lisco Litchfield Lodgepole Long Pine Loomis Lorton Louisville Loup City Lyman Lynch Lyons Macy Madison Madrid Magnet Malcolm Malmo Manley Marquette Marsland Martell Maskell Mason City Max Maxwell Maywood Mc Cook Mc Cool Junction Mcgrew Mclean Mead Meadow Grove Melbeta Memphis Merna Merriman Milford Miller Milligan Mills Minatare Minden Mitchell Monroe Moorefield Morrill Morse Bluff Mullen Murdock Murray Naper Naponee Nebraska City Nehawka Neligh Nelson Nemaha Nenzel Newcastle Newman Grove Newport Nickerson Niobrara Norfolk North Bend North Loup North Platte Oak Oakdale Oakland Oconto Odell Odessa Offutt A F B Ogallala Ohiowa Omaha, Omaha Oneill Ong Orchard Ord Orleans Osceola Oshkosh Osmond Otoe Overton Oxford Page Palisade Palmer Palmyra Panama Papillion Parks Pawnee City Paxton Pender Peru Petersburg Phillips Pickrell Pierce Pilger Plainview Platte Center Plattsmouth Pleasant Dale Pleasanton Plymouth Polk Ponca Potter Prague Primrose Purdum Ragan Randolph Ravenna Raymond Red Cloud Republican City Reynolds Rising City Riverdale Riverton Roca Rockville Rogers Rosalie Roseland Royal Rulo Rushville Ruskin Saint Edward Saint Helena Saint Libory Saint Paul Salem Sargent Saronville Schuyler Scotia Scottsbluff Scribner Seneca Seward Shelby Shelton Shickley Shubert Sidney Silver Creek Smithfield Snyder South Bend South Sioux City Spalding Sparks Spencer Sprague Springfield Springview St Columbans Stamford Stanton Staplehurst Stapleton Steele City Steinauer Stella Sterling Stockville Strang Stratton Stromsburg Stuart Sumner Superior Surprise Sutherland Sutton Swanton Syracuse Table Rock Talmage Taylor Tecumseh Tekamah Thedford Thurston Tilden Tobias Trenton Trumbull Tryon Uehling Ulysses Unadilla Union Upland Utica Valentine Valley Valparaiso Venango Verdigre Verdon Virginia Waco Wahoo Wakefield Wallace Walthill Walton Washington Waterbury Waterloo Wauneta Wausa Waverly Wayne Weeping Water Wellfleet West Point Western Westerville Weston Whiteclay Whitman Whitney Wilber Wilcox Willow Island Wilsonville Winnebago Winnetoon Winside Winslow Wisner Wolbach Wood Lake Wood River Wymore Wynot York Yutan
Site 2 City:
* must provide value
Abie Adams Ainsworth Albion Alda Alexandria Allen Alliance Alma Alvo Amelia Ames Amherst Angora Anselmo Ansley Arapahoe Arcadia Archer Arlington Arnold Arthur Ashby Ashland Ashton Atkinson Atlanta Auburn Aurora Avoca Axtell Ayr Bancroft Barneston Bartlett Bartley Bassett Battle Creek Bayard Beatrice Beaver City Beaver Crossing Bee Beemer Belden Belgrade Bellevue Bellwood Belvidere Benedict Benkelman Bennet Bennington Bertrand Big Springs Bingham Bladen Blair Bloomfield Bloomington Blue Hill Blue Springs Boelus Boys Town Bradshaw Brady Brainard Brewster Bridgeport Bristow Broadwater Brock Broken Bow Brownville Brule Bruning Bruno Brunswick Burchard Burr Burwell Bushnell Butte Byron Cairo Callaway Cambridge Campbell Carleton Carroll Cedar Bluffs Cedar Creek Cedar Rapids Center Central City Ceresco Chadron Chambers Champion Chapman Chappell Chester Clarks Clarkson Clatonia Clay Center Clearwater Cody Coleridge Colon Columbus Comstock Concord Cook Cordova Cortland Cozad Crab Orchard Craig Crawford Creighton Creston Crete Crofton Crookston Culbertson Curtis Dakota City Dalton Danbury Dannebrog Davenport Davey David City Dawson Daykin De Witt Decatur Denton Deshler Deweese Dickens Diller Dix Dixon Dodge Doniphan Dorchester Douglas Du Bois Dunbar Duncan Dunning Dwight Eagle Eddyville Edgar Edison Elba Elgin Elk Creek Elkhorn Ellsworth Elm Creek Elmwood Elsie Elsmere Elwood Elyria Emerson Emmet Enders Endicott Ericson Eustis Ewing Exeter Fairbury Fairfield Fairmont Falls City Farnam Farwell Filley Firth Fordyce Fort Calhoun Franklin Fremont Friend Fullerton Funk Garland Geneva Genoa Gering Gibbon Gilead Giltner Glenvil Goehner Gordon Gothenburg Grafton Grand Island Grant Greeley Greenwood Gresham Gretna Guide Rock Gurley Hadar, Hadar Haigler Hallam Halsey Hampton Hardy Harrisburg Harrison Hartington Harvard Hastings Hay Springs Hayes Center Hazard Heartwell Hebron Hemingford Henderson Hendley Herman Hershey Hickman Hildreth Holbrook Holdrege, Holdrege Holstein Homer Hooper Hordville Hoskins Howells Hubbard Hubbell Humboldt Humphrey Hyannis Imperial Inavale Indianola Inland Inman Ithaca Jackson Jansen Johnson Johnstown Julian Juniata Kearney Kenesaw Kennard Keystone Kilgore Kimball La Vista Lakeside Laurel Lawrence Lebanon Leigh Lemoyne Lewellen Lewiston Lexington Liberty Lincoln Lindsay Linwood Lisco Litchfield Lodgepole Long Pine Loomis Lorton Louisville Loup City Lyman Lynch Lyons Macy Madison Madrid Magnet Malcolm Malmo Manley Marquette Marsland Martell Maskell Mason City Max Maxwell Maywood Mc Cook Mc Cool Junction Mcgrew Mclean Mead Meadow Grove Melbeta Memphis Merna Merriman Milford Miller Milligan Mills Minatare Minden Mitchell Monroe Moorefield Morrill Morse Bluff Mullen Murdock Murray Naper Naponee Nebraska City Nehawka Neligh Nelson Nemaha Nenzel Newcastle Newman Grove Newport Nickerson Niobrara Norfolk North Bend North Loup North Platte Oak Oakdale Oakland Oconto Odell Odessa Offutt A F B Ogallala Ohiowa Omaha, Omaha Oneill Ong Orchard Ord Orleans Osceola Oshkosh Osmond Otoe Overton Oxford Page Palisade Palmer Palmyra Panama Papillion Parks Pawnee City Paxton Pender Peru Petersburg Phillips Pickrell Pierce Pilger Plainview Platte Center Plattsmouth Pleasant Dale Pleasanton Plymouth Polk Ponca Potter Prague Primrose Purdum Ragan Randolph Ravenna Raymond Red Cloud Republican City Reynolds Rising City Riverdale Riverton Roca Rockville Rogers Rosalie Roseland Royal Rulo Rushville Ruskin Saint Edward Saint Helena Saint Libory Saint Paul Salem Sargent Saronville Schuyler Scotia Scottsbluff Scribner Seneca Seward Shelby Shelton Shickley Shubert Sidney Silver Creek Smithfield Snyder South Bend South Sioux City Spalding Sparks Spencer Sprague Springfield Springview St Columbans Stamford Stanton Staplehurst Stapleton Steele City Steinauer Stella Sterling Stockville Strang Stratton Stromsburg Stuart Sumner Superior Surprise Sutherland Sutton Swanton Syracuse Table Rock Talmage Taylor Tecumseh Tekamah Thedford Thurston Tilden Tobias Trenton Trumbull Tryon Uehling Ulysses Unadilla Union Upland Utica Valentine Valley Valparaiso Venango Verdigre Verdon Virginia Waco Wahoo Wakefield Wallace Walthill Walton Washington Waterbury Waterloo Wauneta Wausa Waverly Wayne Weeping Water Wellfleet West Point Western Westerville Weston Whiteclay Whitman Whitney Wilber Wilcox Willow Island Wilsonville Winnebago Winnetoon Winside Winslow Wisner Wolbach Wood Lake Wood River Wymore Wynot York Yutan
Site 3 City:
* must provide value
Abie Adams Ainsworth Albion Alda Alexandria Allen Alliance Alma Alvo Amelia Ames Amherst Angora Anselmo Ansley Arapahoe Arcadia Archer Arlington Arnold Arthur Ashby Ashland Ashton Atkinson Atlanta Auburn Aurora Avoca Axtell Ayr Bancroft Barneston Bartlett Bartley Bassett Battle Creek Bayard Beatrice Beaver City Beaver Crossing Bee Beemer Belden Belgrade Bellevue Bellwood Belvidere Benedict Benkelman Bennet Bennington Bertrand Big Springs Bingham Bladen Blair Bloomfield Bloomington Blue Hill Blue Springs Boelus Boys Town Bradshaw Brady Brainard Brewster Bridgeport Bristow Broadwater Brock Broken Bow Brownville Brule Bruning Bruno Brunswick Burchard Burr Burwell Bushnell Butte Byron Cairo Callaway Cambridge Campbell Carleton Carroll Cedar Bluffs Cedar Creek Cedar Rapids Center Central City Ceresco Chadron Chambers Champion Chapman Chappell Chester Clarks Clarkson Clatonia Clay Center Clearwater Cody Coleridge Colon Columbus Comstock Concord Cook Cordova Cortland Cozad Crab Orchard Craig Crawford Creighton Creston Crete Crofton Crookston Culbertson Curtis Dakota City Dalton Danbury Dannebrog Davenport Davey David City Dawson Daykin De Witt Decatur Denton Deshler Deweese Dickens Diller Dix Dixon Dodge Doniphan Dorchester Douglas Du Bois Dunbar Duncan Dunning Dwight Eagle Eddyville Edgar Edison Elba Elgin Elk Creek Elkhorn Ellsworth Elm Creek Elmwood Elsie Elsmere Elwood Elyria Emerson Emmet Enders Endicott Ericson Eustis Ewing Exeter Fairbury Fairfield Fairmont Falls City Farnam Farwell Filley Firth Fordyce Fort Calhoun Franklin Fremont Friend Fullerton Funk Garland Geneva Genoa Gering Gibbon Gilead Giltner Glenvil Goehner Gordon Gothenburg Grafton Grand Island Grant Greeley Greenwood Gresham Gretna Guide Rock Gurley Hadar, Hadar Haigler Hallam Halsey Hampton Hardy Harrisburg Harrison Hartington Harvard Hastings Hay Springs Hayes Center Hazard Heartwell Hebron Hemingford Henderson Hendley Herman Hershey Hickman Hildreth Holbrook Holdrege, Holdrege Holstein Homer Hooper Hordville Hoskins Howells Hubbard Hubbell Humboldt Humphrey Hyannis Imperial Inavale Indianola Inland Inman Ithaca Jackson Jansen Johnson Johnstown Julian Juniata Kearney Kenesaw Kennard Keystone Kilgore Kimball La Vista Lakeside Laurel Lawrence Lebanon Leigh Lemoyne Lewellen Lewiston Lexington Liberty Lincoln Lindsay Linwood Lisco Litchfield Lodgepole Long Pine Loomis Lorton Louisville Loup City Lyman Lynch Lyons Macy Madison Madrid Magnet Malcolm Malmo Manley Marquette Marsland Martell Maskell Mason City Max Maxwell Maywood Mc Cook Mc Cool Junction Mcgrew Mclean Mead Meadow Grove Melbeta Memphis Merna Merriman Milford Miller Milligan Mills Minatare Minden Mitchell Monroe Moorefield Morrill Morse Bluff Mullen Murdock Murray Naper Naponee Nebraska City Nehawka Neligh Nelson Nemaha Nenzel Newcastle Newman Grove Newport Nickerson Niobrara Norfolk North Bend North Loup North Platte Oak Oakdale Oakland Oconto Odell Odessa Offutt A F B Ogallala Ohiowa Omaha, Omaha Oneill Ong Orchard Ord Orleans Osceola Oshkosh Osmond Otoe Overton Oxford Page Palisade Palmer Palmyra Panama Papillion Parks Pawnee City Paxton Pender Peru Petersburg Phillips Pickrell Pierce Pilger Plainview Platte Center Plattsmouth Pleasant Dale Pleasanton Plymouth Polk Ponca Potter Prague Primrose Purdum Ragan Randolph Ravenna Raymond Red Cloud Republican City Reynolds Rising City Riverdale Riverton Roca Rockville Rogers Rosalie Roseland Royal Rulo Rushville Ruskin Saint Edward Saint Helena Saint Libory Saint Paul Salem Sargent Saronville Schuyler Scotia Scottsbluff Scribner Seneca Seward Shelby Shelton Shickley Shubert Sidney Silver Creek Smithfield Snyder South Bend South Sioux City Spalding Sparks Spencer Sprague Springfield Springview St Columbans Stamford Stanton Staplehurst Stapleton Steele City Steinauer Stella Sterling Stockville Strang Stratton Stromsburg Stuart Sumner Superior Surprise Sutherland Sutton Swanton Syracuse Table Rock Talmage Taylor Tecumseh Tekamah Thedford Thurston Tilden Tobias Trenton Trumbull Tryon Uehling Ulysses Unadilla Union Upland Utica Valentine Valley Valparaiso Venango Verdigre Verdon Virginia Waco Wahoo Wakefield Wallace Walthill Walton Washington Waterbury Waterloo Wauneta Wausa Waverly Wayne Weeping Water Wellfleet West Point Western Westerville Weston Whiteclay Whitman Whitney Wilber Wilcox Willow Island Wilsonville Winnebago Winnetoon Winside Winslow Wisner Wolbach Wood Lake Wood River Wymore Wynot York Yutan
Site 4 City:
* must provide value
Abie Adams Ainsworth Albion Alda Alexandria Allen Alliance Alma Alvo Amelia Ames Amherst Angora Anselmo Ansley Arapahoe Arcadia Archer Arlington Arnold Arthur Ashby Ashland Ashton Atkinson Atlanta Auburn Aurora Avoca Axtell Ayr Bancroft Barneston Bartlett Bartley Bassett Battle Creek Bayard Beatrice Beaver City Beaver Crossing Bee Beemer Belden Belgrade Bellevue Bellwood Belvidere Benedict Benkelman Bennet Bennington Bertrand Big Springs Bingham Bladen Blair Bloomfield Bloomington Blue Hill Blue Springs Boelus Boys Town Bradshaw Brady Brainard Brewster Bridgeport Bristow Broadwater Brock Broken Bow Brownville Brule Bruning Bruno Brunswick Burchard Burr Burwell Bushnell Butte Byron Cairo Callaway Cambridge Campbell Carleton Carroll Cedar Bluffs Cedar Creek Cedar Rapids Center Central City Ceresco Chadron Chambers Champion Chapman Chappell Chester Clarks Clarkson Clatonia Clay Center Clearwater Cody Coleridge Colon Columbus Comstock Concord Cook Cordova Cortland Cozad Crab Orchard Craig Crawford Creighton Creston Crete Crofton Crookston Culbertson Curtis Dakota City Dalton Danbury Dannebrog Davenport Davey David City Dawson Daykin De Witt Decatur Denton Deshler Deweese Dickens Diller Dix Dixon Dodge Doniphan Dorchester Douglas Du Bois Dunbar Duncan Dunning Dwight Eagle Eddyville Edgar Edison Elba Elgin Elk Creek Elkhorn Ellsworth Elm Creek Elmwood Elsie Elsmere Elwood Elyria Emerson Emmet Enders Endicott Ericson Eustis Ewing Exeter Fairbury Fairfield Fairmont Falls City Farnam Farwell Filley Firth Fordyce Fort Calhoun Franklin Fremont Friend Fullerton Funk Garland Geneva Genoa Gering Gibbon Gilead Giltner Glenvil Goehner Gordon Gothenburg Grafton Grand Island Grant Greeley Greenwood Gresham Gretna Guide Rock Gurley Hadar, Hadar Haigler Hallam Halsey Hampton Hardy Harrisburg Harrison Hartington Harvard Hastings Hay Springs Hayes Center Hazard Heartwell Hebron Hemingford Henderson Hendley Herman Hershey Hickman Hildreth Holbrook Holdrege, Holdrege Holstein Homer Hooper Hordville Hoskins Howells Hubbard Hubbell Humboldt Humphrey Hyannis Imperial Inavale Indianola Inland Inman Ithaca Jackson Jansen Johnson Johnstown Julian Juniata Kearney Kenesaw Kennard Keystone Kilgore Kimball La Vista Lakeside Laurel Lawrence Lebanon Leigh Lemoyne Lewellen Lewiston Lexington Liberty Lincoln Lindsay Linwood Lisco Litchfield Lodgepole Long Pine Loomis Lorton Louisville Loup City Lyman Lynch Lyons Macy Madison Madrid Magnet Malcolm Malmo Manley Marquette Marsland Martell Maskell Mason City Max Maxwell Maywood Mc Cook Mc Cool Junction Mcgrew Mclean Mead Meadow Grove Melbeta Memphis Merna Merriman Milford Miller Milligan Mills Minatare Minden Mitchell Monroe Moorefield Morrill Morse Bluff Mullen Murdock Murray Naper Naponee Nebraska City Nehawka Neligh Nelson Nemaha Nenzel Newcastle Newman Grove Newport Nickerson Niobrara Norfolk North Bend North Loup North Platte Oak Oakdale Oakland Oconto Odell Odessa Offutt A F B Ogallala Ohiowa Omaha, Omaha Oneill Ong Orchard Ord Orleans Osceola Oshkosh Osmond Otoe Overton Oxford Page Palisade Palmer Palmyra Panama Papillion Parks Pawnee City Paxton Pender Peru Petersburg Phillips Pickrell Pierce Pilger Plainview Platte Center Plattsmouth Pleasant Dale Pleasanton Plymouth Polk Ponca Potter Prague Primrose Purdum Ragan Randolph Ravenna Raymond Red Cloud Republican City Reynolds Rising City Riverdale Riverton Roca Rockville Rogers Rosalie Roseland Royal Rulo Rushville Ruskin Saint Edward Saint Helena Saint Libory Saint Paul Salem Sargent Saronville Schuyler Scotia Scottsbluff Scribner Seneca Seward Shelby Shelton Shickley Shubert Sidney Silver Creek Smithfield Snyder South Bend South Sioux City Spalding Sparks Spencer Sprague Springfield Springview St Columbans Stamford Stanton Staplehurst Stapleton Steele City Steinauer Stella Sterling Stockville Strang Stratton Stromsburg Stuart Sumner Superior Surprise Sutherland Sutton Swanton Syracuse Table Rock Talmage Taylor Tecumseh Tekamah Thedford Thurston Tilden Tobias Trenton Trumbull Tryon Uehling Ulysses Unadilla Union Upland Utica Valentine Valley Valparaiso Venango Verdigre Verdon Virginia Waco Wahoo Wakefield Wallace Walthill Walton Washington Waterbury Waterloo Wauneta Wausa Waverly Wayne Weeping Water Wellfleet West Point Western Westerville Weston Whiteclay Whitman Whitney Wilber Wilcox Willow Island Wilsonville Winnebago Winnetoon Winside Winslow Wisner Wolbach Wood Lake Wood River Wymore Wynot York Yutan
Site 1 State:
* must provide value
Site 2 State:
* must provide value
Site 3 State:
* must provide value
Site 4 State:
* must provide value
Site 1 Zip Code:
* must provide value
Site 2 Zip Code:
* must provide value
Site 3 Zip Code:
* must provide value
Site 4 Zip Code:
* must provide value
Site 1 County:
* must provide value
Adams Antelope Arthur Banner Blaine Boone Box Butte Boyd Brown Buffalo Burt Butler Cass Cedar Chase Cherry Cheyenne Clay Colfax Cuming Custer Dakota Dawes Dawson Deuel Dixon Dodge Douglas Dundy Educational Service Unit Districts Fillmore Franklin Frontier Furnas Gage Garden Garfield Gosper Grant Greeley Hall Hamilton Harlan Hayes Hitchcock Holt Hooker Howard Jefferson Johnson Kearney Keith Keya Paha Kimball Knox Lancaster Lincoln Logan Loup Madison Mcpherson Merrick Morrill Nance Nemaha Nuckolls Otoe Pawnee Perkins Phelps Pierce Platte Polk Red Willow Richardson Rock Saline Sarpy Saunders Scotts Bluff Seward Sheridan Sherman Sioux Stanton Thayer Thomas Thurston Valley Washington Wayne Webster Wheeler York
Site 2 County:
* must provide value
Adams Antelope Arthur Banner Blaine Boone Box Butte Boyd Brown Buffalo Burt Butler Cass Cedar Chase Cherry Cheyenne Clay Colfax Cuming Custer Dakota Dawes Dawson Deuel Dixon Dodge Douglas Dundy Educational Service Unit Districts Fillmore Franklin Frontier Furnas Gage Garden Garfield Gosper Grant Greeley Hall Hamilton Harlan Hayes Hitchcock Holt Hooker Howard Jefferson Johnson Kearney Keith Keya Paha Kimball Knox Lancaster Lincoln Logan Loup Madison Mcpherson Merrick Morrill Nance Nemaha Nuckolls Otoe Pawnee Perkins Phelps Pierce Platte Polk Red Willow Richardson Rock Saline Sarpy Saunders Scotts Bluff Seward Sheridan Sherman Sioux Stanton Thayer Thomas Thurston Valley Washington Wayne Webster Wheeler York
Site 3 County:
* must provide value
Adams Antelope Arthur Banner Blaine Boone Box Butte Boyd Brown Buffalo Burt Butler Cass Cedar Chase Cherry Cheyenne Clay Colfax Cuming Custer Dakota Dawes Dawson Deuel Dixon Dodge Douglas Dundy Educational Service Unit Districts Fillmore Franklin Frontier Furnas Gage Garden Garfield Gosper Grant Greeley Hall Hamilton Harlan Hayes Hitchcock Holt Hooker Howard Jefferson Johnson Kearney Keith Keya Paha Kimball Knox Lancaster Lincoln Logan Loup Madison Mcpherson Merrick Morrill Nance Nemaha Nuckolls Otoe Pawnee Perkins Phelps Pierce Platte Polk Red Willow Richardson Rock Saline Sarpy Saunders Scotts Bluff Seward Sheridan Sherman Sioux Stanton Thayer Thomas Thurston Valley Washington Wayne Webster Wheeler York
Site 4 County:
* must provide value
Adams Antelope Arthur Banner Blaine Boone Box Butte Boyd Brown Buffalo Burt Butler Cass Cedar Chase Cherry Cheyenne Clay Colfax Cuming Custer Dakota Dawes Dawson Deuel Dixon Dodge Douglas Dundy Educational Service Unit Districts Fillmore Franklin Frontier Furnas Gage Garden Garfield Gosper Grant Greeley Hall Hamilton Harlan Hayes Hitchcock Holt Hooker Howard Jefferson Johnson Kearney Keith Keya Paha Kimball Knox Lancaster Lincoln Logan Loup Madison Mcpherson Merrick Morrill Nance Nemaha Nuckolls Otoe Pawnee Perkins Phelps Pierce Platte Polk Red Willow Richardson Rock Saline Sarpy Saunders Scotts Bluff Seward Sheridan Sherman Sioux Stanton Thayer Thomas Thurston Valley Washington Wayne Webster Wheeler York
Site 1:
Name of facility Address City State NE Zip code County
Site 2:
Name of facility Address City State NE Zip code County
Site 3:
Name of facility Address City State NE Zip code County
Site 4:
Name of facility Address City State NE Zip code County
Will you be working part time or full time? (40 hours per week on average is generally considered full time and qualifies for the full award; time spent on call should not be counted. An average of at least 20 hours per week is required for part time/a partial award.)
* must provide value
Part time
Full time
Have you ever participated in a loan repayment or loan forgiveness program? If no, select 0. Otherwise you can list up to 3 programs.
* must provide value
0 1 2 3
Program 1 name:
* must provide value
Program 2 name:
* must provide value
Program 3 name:
* must provide value
Program 1 source:
* must provide value
Federal State Private Other
Program 2 source:
* must provide value
Federal State Private Other
Program 3 source:
* must provide value
Federal State Private Other
Program 1 Date Completed:
* must provide value
Today M-D-Y
Program 2 Date Completed:
* must provide value
Today M-D-Y
Program 3 Date Completed:
* must provide value
Today M-D-Y
Program 1 total amount received:
* must provide value
Program 2 total amount received:
* must provide value
Program 3 total amount received:
* must provide value
Repayment Program 1:
Name of Program Source Date Completed Total Amount Received
Repayment Program 2:
Name of Program Source Date Completed Total Amount Received
Repayment Program 3:
Name of Program Source Date Completed Total Amount Received
Matching funds are generally required for participation in these programs. These questions ask about the entity that will be providing those matching funds, the "Local Entity". Matching funds cannot be provided by the person receiving loan repayment.
You listed ______
* must provide value
Yes
No
Match name of facility:
* must provide value
Match Address:
* must provide value
Match City:
* must provide value
Match State:
* must provide value
AA AE AK AL AP AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UM UT VA VI VT WA WI WV WY
Match Zip code:
* must provide value
You answered no for site 1 practice as matching funds entity. Please list who will be responsible for the local match below:
Name of facility Address City State Zip code
Please enter email address of the individual who will fill out the "Application for Community Participation" (this should be a contact for the Local Entity and NOT your email address):
* must provide value
Are any of your loans subject to cancellation? If you plan to participate in Public Service Loan Forgiveness (PSLF), please select Yes and explain below, including expected date of completion.
* must provide value
Yes
No
Please explain:
* must provide value
Have you ever defaulted on a federal payment obligation?
* must provide value
Yes
No
Please explain:
* must provide value
Have you had any federal or non-federal debt written off as uncollectible?
* must provide value
Yes
No
Date of judgement:
* must provide value
Today M-D-Y
Have you ever filed for bankruptcy?
* must provide value
Yes
No
Date of bankruptcy:
* must provide value
Today M-D-Y
Complete the following information for any outstanding educational loans:
What is your current outstanding balance on all government or commercial educational loans?
* must provide value
For example, enter 150000.00 for $150,000.00
In one paragraph or less, why do you wish to live and work in this area?
* must provide value
You will need to upload documentation from your lender(s) indicating your name, current loan balance, and contact information of the lender. Please upload info for all eligible loans as one pdf document. Documentation should clearly specify that the loan was received to support your undergraduate or graduate education that led to the completion of your current professional training and licensure. You can request a "credit report-account summary letter" or "Loan Summary Letter" from your lender, or print the information from the internet if available. If any eligible loan is consolidated or refinanced with a non-educational loan, no portion of the consolidated/refinanced loan is eligible for loan repayment. If your application is approved, the amount of repayment you receive will be based on your current loan balance within six month of beginning your practice obligation.
* must provide value
Please click on this link to open W-9 & ACH enrollment form:W9/ACH Enrollment Form Use your personal info, make sure to fill out all required fields, and sign in both of the two areas requiring it (middle and bottom of sheet).
* must provide value
Please attach a copy of blank/voided check:
* must provide value
For the purpose of complying with Neb Rev. Stat. SS 4-108 through 4-114, I attest as follows:
* must provide value
I am a citizen of the United States.
I am a qualified alien under the federal immigration and Nationality Act.
My immigration status and alien number are as follows: I agree to provide a copy of my USCIS documentation upon request.
* must provide value
Please enter your immigtation status and alien number.
I hereby attest that my response and the information provided on this form and any related application for public benefits are true, complete, and accurate and I understand that this information may be used to verify my lawful presence in the United States.______ ______ ______
* must provide value
Signature Date:
* must provide value
Today M-D-Y
Name : ______ ______ ______
Programs qualified based on profession and/or specialty:
* must provide value
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Calculate Text Entity Name:
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Calculate Text Entity City:
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Calculate Text Entity Zip Code:
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