Loan Repayment 2016

Organization: Rosemary Castro - Individual

Certifications

LoanRepayment-2016-CastroR (1) - Individual-01610

Information Release
I authorize staff to verify my employment if I am awarded. I understand that the information provided will include
my employment history and position status. Any information obtained through this release is to be kept
confidential by the Office of Statewide Health Planning and Development. This authorization is valid for five (5)
years from the date of this form.

*Acknowledgement: aI Agree
00100000
Application Certification
Allied Healthcare Loan Repayment Program (AHLRP)
I certify that all information in this application is true and accurate to the best of my knowledge. I authorize the
Health Professions Education Foundation (HPEF) to verify any information submitted as part of this
application. I understand that falsification of information contained in this application will disqualify my
application and that the respective licensing Board of California or Registry will be notified. I understand that if
falsification is discovered after I have been awarded or if I breach my contract, I will be required to repay all
funds awarded, plus interest and administrative fees. I understand that once submitted, my application and
supporting documents become the property of HPEF. I also understand that my personal statement becomes
the property of HPEF and may be used, including but not limited to, advertising/marketing, program reports,
newsletters, and other publications.
I understand that, if awarded the Allied Healthcare Loan Repayment, I am agreeing to the below terms:
Return all correspondence in a timely mannerAttend a mandatory orientation conference callPrint, sign, and
mail a contract. I would be entering into a signed, written agreement with California States Office of Statewide
Health Planning and DevelopmentSend two (2) years of the most current Tax Returns for myself and my spouse
(if applicable)Maintain employment at qualified (MUA, HPSA, County, State, VA and Correctional)
facilityContinue to perform my work duties in the position of which I applied for this Loan RepaymentFor a
period of twelve (12) months:
Work full-time (minimum of thirtytwo (32) hours per week)Work in direct patient care (minimum of thirtytwo
(32) hours per week)Send in all required paperwork by requested deadlines; including Employment
Verification Forms and Progress Reports, signed by my supervisor(s) to verify that I am still working and
meeting program requirementsNot accept any other awards from HPEF, State Loan Repayment Program,
National Health Service Corps or other entities, which require me to fulfill a contract that overlaps with this
periodLet OSHPD know of any changes to my address, email, phone number, student loans, employment, and
professional registration/license to practice, or leaves of absence from workRepay all funds received, including
interest, if I do not comply with the contract

* I Agree
Licensed Vocational Nurse Loan Repayment Program (LVNLRP)
I certify that all information in this application is true and accurate to the best of my knowledge. I authorize the
Health Professions Education Foundation (HPEF) to verify any information submitted as part of this
application. I understand that falsification of information contained in this application will disqualify my
application and the respective licensing Board will be notified. I understand that if falsification is discovered
after I have been awarded or if I breach my contract, I will be required to repay all funds awarded, plus interest
and administrative fees. I understand that once submitted, my application and supporting documents become
the property of HPEF. I also understand that my personal statement becomes the property of HPEF and may
be used, including but not limited to, advertising/marketing, program reports, newsletters, and other
publications.
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Loan Repayment 2016

Organization: Rosemary Castro - Individual
Certifications

LoanRepayment-2016-CastroR (1) - Individual-01610

I understand that, if awarded the Licensed Vocational Nurse Loan Repayment, I am agreeing to the below
terms:
Return all correspondence in a timely mannerAttend a mandatory orientation conference callPrint, sign, and
mail a contract. I would be entering into a signed, written agreement with California States Office of Statewide
Health Planning and DevelopmentSend two (2) years of the most current Tax Returns for myself and my spouse
(if applicable)Maintain employment at qualified (MUA, HPSA, County, State, VA and Correctional)
facilityContinue to perform my work duties as a Licensed Vocational NurseFor a period of twenty-four (24)
months:
Work full-time (minimum of thirtytwo (32) hours per week)Work in direct patient care (minimum of thirtytwo
(32) hours per week)Send in all required paperwork by requested deadlines; including Employment
Verification Forms and Progress Reports, signed by my supervisor(s) to verify that I am still working and
meeting program requirementsNot accept any other awards from HPEF, State Loan Repayment Program,
National Health Service Corps or other entities, which require me to fulfill a contract that overlaps with this
periodLet OSHPD know of any changes to my address, email, phone number, student loans, employment, and
professional registration/license to practice, or leaves of absence from workRepay all funds received, including
interest, if I do not comply with the contract

* I Agree
Bachelor of Science Nursing Loan Repayment Program (BSNLRP)
I certify that all information in this application is true and accurate to the best of my knowledge. I authorize the
Health Professions Education Foundation (HPEF) to verify any information submitted as part of this
application. I understand that falsification of information contained in this application will disqualify my
application and that the Board of Registered Nursing will be notified. I understand that if falsification is
discovered after I have been awarded or if I breach my contract, I will be required to repay all funds awarded,
plus interest and administrative fees. I understand that once submitted, my application and supporting
documents become the property of HPEF. I also understand that my personal statement becomes the property
of HPEF and may be used, including but not limited to, advertising/marketing, program reports, newsletters,
and other publications.
I understand that, if awarded the Bachelor of Science in Nursing Loan Repayment, I am agreeing to the below
terms:
Return all correspondence in a timely mannerAttend a mandatory orientation conference callPrint, sign, and
mail a contract. I would be entering into a signed, written agreement with California States Office of Statewide
Health Planning and DevelopmentSend two (2) years of the most current Tax Returns for myself and my spouse
(if applicable)Send my Transcripts that indicate degree conferred Maintain employment at qualified (MUA,
HPSA, County, State, VA and Correctional) facilityContinue to perform my work duties as a Licensed
Vocational NurseFor a period of twenty-four (24) months:
Work full-time (minimum of thirtytwo (32) hours per week)Work in direct patient care (minimum of thirtytwo
(32) hours per week)Send in all required paperwork by requested deadlines; including Employment
Verification Forms and Progress Reports, signed by my supervisor(s) to verify that I am still working and
meeting program requirementsNot accept any other awards from HPEF, State Loan Repayment Program,
National Health Service Corps or other entities, which require me to fulfill a contract that overlaps with this
periodLet OSHPD know of any changes to my address, email, phone number, student loans, employment, and
professional registration/license to practice, or leaves of absence from workRepay all funds received, including
interest, if I do not comply with the contract

*aI Agree
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Loan Repayment 2016

Organization: Rosemary Castro - Individual
Certifications

LoanRepayment-2016-CastroR (1) - Individual-01610

Advanced Practice Healthcare Loan Repayment Program (APHLRP)

I certify that all information in this application is true and accurate to the best of my knowledge. I authorize the
Health Professions Education Foundation (HPEF) to verify any information submitted as part of this
application. I understand that falsification of information contained in this application will disqualify my
application and the respective licensing Board will be notified. I understand that if falsification is discovered
after I have been awarded or if I breach my contract, I will be required to repay all funds awarded, plus interest
and administrative fees. I understand that once submitted, my application and supporting documents become
the property of HPEF. I also understand that my personal statement becomes the property of HPEF and may
be used, including but not limited to, advertising/marketing, program reports, newsletters, and other
publications.
I understand if awarded the Advanced Practice Healthcare Loan Repayment, I am agreeing to the below terms:
Return all correspondence in a timely mannerAttend a mandatory orientation conference callPrint, sign, and
mail a contract. I would be entering into a signed, written agreement with California States Office of Statewide
Health Planning and DevelopmentSend two (2) years of the most current Tax Returns for myself and my spouse
(if applicable)Maintain employment at qualified (MUA, HPSA, County, State, VA and Correctional)
facilityContinue to perform my work duties in the position to which I applied for this Loan RepaymentFor a
period of twenty-four (24) months:
Work full-time (minimum of thirtytwo (32) hours per week)Work in direct patient care (minimum thirtytwo (32)
hours)Send in all required paperwork by requested deadlines; including Employment Verification Forms and
Progress Reports, signed by my supervisor(s) to verify that I am still working and meeting program
requirementsNot accept any other awards from HPEF, State Loan Repayment Program, National Health
Service Corps or other entities, which require me to fulfill a contract that overlaps with this periodLet OSHPD
know of any changes to my address, email, phone number, student loans, employment, and professional
registration/license to practice, or leaves of absence from workRepay all funds received, including interest, if I
do not comply with the contract

* I Agree
Licensed Mental Health Service Provider Education Program (LMHSPEP)
I certify that I am the person herein named submitting this application; that I have read the complete application,
know the full content thereof, and declare under penalty of perjury, that all of the information contained herein
and evidence or other credentials submitted herewith are true and correct and that I am willing to sign, or have
signed a written contract with a practice setting committing to a minimum two (2) years providing direct client
care for 32 hours or more per week in a qualified facility. I authorize HPEF to verify any information submitted
as part of this application. I understand that falsification of information contained in this application will
disqualify my application. I understand that once submitted my application and supporting documents become
the property of HPEF and selected non-confidential information may be used including but not limited to,
advertising/marketing, program reports, newsletters, and other publications.
I understand that, if awarded the Licensed Mental Health Services Provider Education Program, I am agreeing
to the below terms:
Return all correspondence in a timely mannerAttend a mandatory orientation conference callPrint, sign, and
mail a contract. I would be entering into a signed, written agreement with California States Office of Statewide
Health Planning and DevelopmentMaintain employment at qualified facilityContinue to perform my work duties
in the position to which I applied for this Loan RepaymentFor a period of twenty-four (24) months:
Work full-time (minimum of thirtytwo (32) hours per week)Work in direct patient care (minimum thirtytwo (32)
hours)Send in all required paperwork by requested deadlines; including Employment Verification Forms and
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Loan Repayment 2016

Organization: Rosemary Castro - Individual
Certifications

LoanRepayment-2016-CastroR (1) - Individual-01610

Progress Reports, signed by my supervisor(s) to verify that I am still working and meeting program
requirementsNot accept any other awards from HPEF, State Loan Repayment Program, National Health
Service Corps or other entities, which require me to fulfill a contract that overlaps with this periodLet OSHPD
know of any changes to my address, email, phone number, student loans, employment, and professional
registration/license to practice, or leaves of absence from workRepay all funds received, including interest, if I
do not comply with the contract

* I Agree
Mental Health Loan Assumption Program (MHLAP)
I certify that I am the person herein named submitting this application; that I have read the complete application,
know the full content thereof, and declare under penalty of perjury, that all of the information contained herein
and evidence or other credentials submitted herewith are true and correct and that I am willing to sign, or have
signed a written contract with a practice setting committing to a minimum one year of full-time or part-time
practice in the Public Mental Health System. I authorize HPEF to verify any information submitted as part of this
application. I understand that falsification of information contained in this application will disqualify my
application. I understand that once submitted my application and supporting documents become the property of
HPEF and selected non-confidential information may be used including but not limited to,
advertising/marketing, program reports, newsletters, and other publications.
I understand that, if awarded the Mental Health Loan Assumption Program, I am agreeing to the below terms:
Return all correspondence in a timely mannerAttend a mandatory orientation conference callPrint, sign, and
mail a contract. I would be entering into a signed, written agreement with California States Office of Statewide
Health Planning and DevelopmentMaintain employment in the county Public Mental Health System
(PMHS)Continue to perform my work duties in the position to which I applied for this Loan RepaymentFor a
period of twelve (12) months:
Work minimum of twenty (20) hours per weekSend in all required paperwork by requested deadlinesNot
accept any other awards from HPEF, State Loan Repayment Program, National Health Service Corps or other
entities, which require me to fulfill a contract that overlaps with this periodLet OSHPD know of any changes to
my address, email, phone number, student loans, employment, and professional registration/license to
practice, or leaves of absence from work

* I Agree
Steven M. Thompson Physician Corps Loan Repayment Program (STLRP)
I certify that I am the person herein named subscribing to this application. I have read the complete application,
know the full content thereof, and declare under penalty of perjury, that all of the information contained herein
and evidence or other credentials submitted herewith are true and correct. I am willing to sign, or have signed a
written agreement with a practice setting committing to a minimum three years of full-time practice (40 hours
per week) in a medically underserved area. I authorize OSHPD to verify any information submitted as part of
this application. I understand that falsification of information contained in this application will disqualify my
application. I understand that once submitted my application and supporting documents become the property of
OSHPD. I also understand that my personal statement becomes the property of the OSHPD and may be used,
including but not limited to, advertising/marketing, program reports, newsletters, and other publications.
I understand that, if awarded the Steven M. Thompson Physician Corps Loan Repayment, I am agreeing to the
below terms:
Return all correspondence in a timely mannerAttend a mandatory orientation conference callPrint, sign, and
mail a contract. I would be entering into a signed, written agreement with California States Office of Statewide
Health Planning and DevelopmentMaintain employment at qualified (HPSA or PCSA) facilityContinue to
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Loan Repayment 2016

Organization: Rosemary Castro - Individual
Certifications

LoanRepayment-2016-CastroR (1) - Individual-01610

perform my work duties in the position to which I applied for this Loan RepaymentFor a period of thirty-six (36)
months:
Work full-time (minimum of forty (40) hours per week) for a minimum of 45 weeks per yearWork in direct patient
care (minimum thirtytwo (32) hours per week)Send in all required paperwork by requested deadlinesNot
accept any other awards from HPEF, State Loan Repayment Program, National Health Service Corps or other
entities, which require me to fulfill a contract that overlaps with this periodLet OSHPD know of any changes to
my address, email, phone number, student loans, employment, and professional registration/license to
practice, or leaves of absence from workRepay all funds received, including interest, if I do not comply with the
contract

* I Agree
California State Loan Repayment Program (SLRP)
I certify that I am the person herein named subscribing to this application; that I have read the complete
application, know the full content thereof, and declare under penalty of perjury, that all of the information
contained herein and evidence or other credentials submitted herewith are true and correct and that I am willing
to sign, or have signed a written agreement with a practice setting committing to a minimum two years of
service. I authorize representatives of the Office of Statewide Health Planning and Development (OSHPD) to
contact educational institutions I attended, institutions holding any of the listed educational loans, and
employers to verify the accuracy of the information contained in this application. I understand that once
submitted, my application and supporting documents become the property of OSHPD. I also understand that
my personal statements become the property of OSHPD and may be used, including but not limited to,
advertising/marketing, program reports, newsletters, and other publications.

* I Agree
You cannot submit your application until the Site Administrator has completed their portion (Practice Site
Certification and MOU pages).
View Definitions page

When finished, click Save and Continue.

To submit your application, click on the Status Change page, and change the status to
"Basic Application Submitted."

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