Dentist Loan Repayment Program Application

Personal information

Name*

First Name

Initial

Last Name

Address*

Address Line 1

City

State

ZIP Code

Email*

Phone*

Date of birth*

Professional information

Dental school attended*

Degree awarded*

Year graduated*

Practitioner type*

General practitioner Specialist

Specialty field

Disciplinary sanction*

Yes No

Were you ever formally sanctioned by your dental school and/or university for any academic, clinical, or code of conduct issues?

Disciplinary sanction description

Please describe the issue and sanction.

License Number

Licensing state

Additional license number

Additional licensing state

Practice name*

Practice address*

Address Line 1

City

State

ZIP Code

Service option / Loan repayment selection

Loan balance estimate* $

Existing service obligation? *

Yes No

Do you have an existing service oblication in return for scholarship, loan forgiveness, or loan repayment?

Service obligation description

Please describe your existing service obligation.

Service option / loan repayment selection*

Option 1 Option 2

Option 1:

For loan repayments of $15,000 per year, up to a total of $75,000, I agree to see 15% Medicaid patients in my practice.

I also agree to accept one patient/case per award year from the Donated Dental Services Program or an approved alternative.

Option 2:

For loan repayments of $25,000 per year, up to a total of $125,000, I agree to see 30% Medicaid patients in my practice.

I also agree to accept two patients/cases per award year from the Donated Dental Services Program or an approved alternative.

Expressions of interest

Commitment to the underserved*

Community and volunteer exprience*

Community oral health needs*

Practice location considerations*