Date: __________________

Name:                 _____________________________

Street Address: _____________________________

City, State, Zip: _____________________________

Post-Resident Service Obligation

Self-Certification Form

For Primary Care Loans Made After 11/13/98

We recommend that you read your promissory note carefully in order to become familiar with a number of features, duties and more specifically, what (is) and what (is not) available relating to the PCL agreement.

Agreement…to enter and practice primary health care within 4 years after the date of graduation.

Agreement…practice primary care until PCL is paid in full.

Agreement…primary care is defined as family medicine, general internal medicine, general pediatrics, preventative medicine or osteopathic general practice.

Agreement…residency training program in PHC is defined as a 3-year residency program in all pathic or osteopathic family medicine, internal medicine, combined medicine/pediatrics or preventative medicine.

Agreement…Non-Compliance, I understand, if I am not practicing primary health care as defined above as a required part of the Primary Care Loan Program, interest will accrue at a rate of 18% from the date of non-compliance.

School Name: _________________________________________

Borrower Name: _______________________________________

Account No: __________________________________________

Please check one of the following:

[ ] This is to certify that I am and will be practicing Primary Health Care as defined above for the next twelve months. I understand that I must inform my school of my status annually until my PCL is paid in full.

[ ] This is to certify that I am no longer practicing Primary Health Care as defined above and as required part of the Primary Care Loan agreement and program, effective date ___________________________.

Please complete the following:

______________________________________

Specialty

______________________________________

Residency/Practice Address

______________________________________

City State Zip

______________________________________

Work Phone Number