Haw. Code R. § tit. 11, subtit. 1, ch. 351, Application for Nursing Student Loan Program

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Application for Nursing Student Loan Program

Department of Health State of Hawai'i

APPLICATION FOR NURSING STUDENT LOAN PROGRAM

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Section I: PERSONAL DATA

Name__________________________________________________________

(Last) (First) (Middle)

Address_________________________________________________________

(City) (State) (Zip Code)

Phone () ___-____ Social Security No._____-_____-_____

If you are NOT a U.S. citizen, are you eligible for employment in the U.S.? * Yes* No

Name and address of nearest relative NOT residing with you

Name____________________________Relationship_____________________

Address___________________________________Phone () ____-_____

Please provide one personal and one professional reference

Personal Reference (Do NOT list a relative)

Name____________________________Relationship_____________________

Address____________________________________Phone () _____-_____

Professional Reference (Do NOT list a supervisor)

Name____________________________Relationship_____________________

Address____________________________________Phone () _____-_____

APPLICATION FOR NURSING STUDENT LOAN PROGRAM

Section II: EDUCATIONAL INFORMATION

NAME AND LOCATION SCHOOLS ATTENDED	YEARS ATTNDED	MAJOR	DEGREE/ DIPLOMA
HIGH SCHOOL
COLLEGE


OTHER SCHOOLING

Name of Nursing School Attending_______________________________________

Status: * Accepted into Nursing Program

* Not accepted into Nursing Program

* Pending (explain)____________________________________________

Enrollment Date_____________________________________________________

Anticipated Graduation Date___________________________________________

Grade Point Average (based on 4.0 scale)__________________________________

Degree Pursued_____________________________________________________

APPLICATION FOR NURSING STUDENT LOAN PROGRAM

Section III: EMPLOYMENT INFORMATION

Please begin with your most recent employment

Employer__________________________________Phone No. () _____-_______

Address__________________________________________________________

Name and Title of Supervisor__________________________________________

Your Title________________________________________________________

From_________________To_________________* Full Time * Part Time

Employer__________________________________Phone No. () _____-_______

Address__________________________________________________________

Name and Title of Supervisor__________________________________________

Your Title________________________________________________________

From_________________To_________________* Full Time * Part Time

Employer__________________________________Phone No. () _____-_______

Address__________________________________________________________

Name and Title of Supervisor__________________________________________

Your Title________________________________________________________

From_________________To_________________* Full Time * Part Time

Employer__________________________________Phone No. () _____-_______

Address__________________________________________________________

Name and Title of Supervisor__________________________________________

Your Title________________________________________________________

From_________________To_________________* Full Time * Part Time

APPLICATION FOR NURSING STUDENT LOAN PROGRAM

Section IV: FINANCIAL INFORMATION

For what funding you are applying? (Maximum $10,000 per year)

* Tuition

* Expenses

* Tuition and Expenses

Please complete the following information

Total annual gross income $____________

Total monthly expenses $____________

Please summarize your monthly financial needs and expenses on the reverse side of this page

Indicate entire loan amount requested by semester or quarter

Semester/Quarter	Tuition	Other Expenses	Total Expenses








TOTAL

Other financial assistance information

INSTITUTION	TYPE ASSISTANCE	ASSISTANCE
INSTITUTION	TYPE ASSISTANCE	APPLIED FOR	RECEIVING

APPLICATION FOR NURSING STUDENT LOAN PROGRAM

Section V: STATEMENT OF PERSONAL AND PROFESSIONAL GOALS

Discuss your reasons for applying for this loan. Include information on your background; school and community activities in which you have participated; awards and special recognition you have received; your hobbies and interests; the reasons you have for becoming a nurse; and your future career goals. Attach additional page(s) if necessary.

APPLICATION FOR NURSING STUDENT LOAN PROGRAM

Section VI:

I certify that the information provided in this application is truthful.

I have read the Nursing Student Loan Program General Application Information and Instructions and understand and accept the employment/repayment obligations associated with participating in this loan program.

____________________________________________________________________

Applicants Signature Date

The following shall be submitted together:

1. Completed application

2. Statement of Personal and Professional Goals

3. Copies of all high school and college transcription

4. Verification of grade point average

5. Notarized Letter of Intent to work as a registered nurse with an institution or organization providing direct clinical care in Hawai'i for a minimum of three year after obtaining a license under chapter 457, the Hawai'i Revised Statutes

Application and required attachments shall be submitted to:

Department of Health

State of Hawai'i

Division of Community Hospitals

1270 Queen Emma Street, Suite 1200

ATTN: NURSING STUDENT LOAN PROGRAM

Honolulu, Hawaii 96813

APPLICATION FOR NURSING STUDENT LOAN APPLICATION

NOTICE OF INTENT

Name_______________________________________________________

Social Security Number ______-______-_______

Total Repayment (Amount Requesting) Obligation $______________

I agree to work as a registered nurse or as a nurse practitioner with an institution or organization providing direct clinical care in Hawai'i for a minimum of three years of obtaining a license pursuant to chapter 457 of the Hawai'i ] Statutes.

I,_________________________________________________, certify that I am a student registered in a full-tin accredited specialized nursing educational program as defined by an accredited degree-granting university, college nursing institution in Hawai'i or the mainland and meet the eligibility requirements to obtain a loan under the Nursing Student Loan Program. I have read and agree to comply with the terms outlined in the Nursing Student Loan Program General Application Information and Instructions. I understand that if awarded a loan, the loan amount will be paid to me each semester upon submission of the following:

1. Transcripts from the previous academic semester indicating a minimum GPA of 2.0 (based on a 4.0 scale).

2. A letter from the school of nursing confirming successful completion of the previous semester.

I understand that upon graduation, I must obtain employment as a registered nurse or a nurse practitioner in Hawai'i for a minimum of three years immediately following obtaining a license under chapter 457, Hawai'i Revised Statutes. I understand that for each full year (12 months) of continuous employment as outlined above, twenty per cent of my total repayment obligation will be forgiven. To cancel the entire obligation shall require five years of employment.

I understand that any leaves of absence will cause the fulfillment date of my obligation to be adjusted. I also understand that the repayment obligation amount is due immediately upon any of the following conditions:

1. I withdraw from nursing studies prior to graduation or convert to part-time status.

2. I graduate but do not seek employment.

3. I graduate and become licensed but I become employed in the State in a profession other than as a registered nurse.

4. I graduate and become employed in any field outside the State of Hawai'i

______________________________________________________________

(Name)

______________________________________________________________

(Signature) (Date)

Subscribed and sworn to before me this ____day of_____,199___.

Notary Public, State of Hawai'i

My commission expires:

STATE OF HAWAI'I

DEPARTMENT OF HEALTH

NURSING STUDENT LOAN PROGRAM

GENERAL APPLICATION INFORMATION AND INSTRUCTIONS

OVERVIEW

Nursing students may receive financial assistance through a restricted loan program as they pursue an accredited specialized nursing education program with an accredited degree-granting university, college, or nursing institution in the State of Hawaii In the event that no accredited specialized nursing educational programs are available in the State of Hawai'i, consideration for loan approval with an accredited degree-granting or certificate-granting university, college, or nursing institution outside the State of Hawai'i may be given The program will run from July 1,1991 to June 30,1995, or until all available funds are expended, whichever comes first Loan recipients are expected to repay their loans by June 30, 2000.

The Department of Health, State of Hawai'i provides services and opportunities to take part in its programs and activities without regard to race, color, national origin, age, disability, or sexual orientation.

FUNDING AVAILABLE

Funding under this loan program is limited to a maximum of $10,000 per student per academic year, not to exceed five years.

Low interest loans are available to persons who are studying to become licensed registered nurses and who intend to work in Hawai'i. The loan amounts shall be used for:

1. Payment of tuition.

2. Other necessary financial assistance in connection with obtaining a degree or certificate from an accredited degree-granting university, college, or nursing institution in Hawai'i.

3. "Matching funds" to secure grants from other sources.

MINIMUM SELECTION CRITERIA

Applicants shall:

1. Be a student pursuing a career as a registered nurse.

2. Have been accepted and classified as a full-time nursing student by the applicant's respective school.

3. Have been a Hawai'i resident for at least one year prior to the date the applicant applies for a loan.

4. Have not previously graduated from a similar nursing program and is not repeating any nursing-related courses.

5. Intend to become licensed and obtain employment as a registered nurse directly providing or supervising clinical care immediately upon graduation and work in Hawaii for a minimum of three years.

APPLICATION PROCESS

Applicants shall submit:

1. Completed "Application for Nursing Student Loan Program."

2. A confirmation from an accredited degree-granting university, college, or nursing institution confirming that the applicant is either a current student or will be commencing studies in the upcoming academic semester.

3. Official copies of college transcripts. Applicants who have not previously attended college shall submit high school transcripts.

4. A written essay on the applicant's personal and professional goals using the form provided by the department.

5. A written notarized form provided by the department, which indicates the applicant intends to work as a registered nurse in Hawaii for a minimum of three years immediately following obtaining a license under chapter 457, Hawai'i Revised Statutes.

At the discretion of the Loan Advisory Committee, applicants may be subject to a credit verification and will be notified of this check when applying for the loan.

Applications and required attachments listed above shall be submitted together to:

Department of Health

State of Hawai'i

Division of Community Hospitals

1270 Queen Emma Street, Suite 1200

ATTN: NURSING STUDENT LOAN PROGRAM

Honolulu, Hawai'i 96813

Applications may be obtained from the Office of the Director of the Department of Health at 1250 Punchbowl Street, 3rd Floor. Applicants may also call 586-3991 to receive a packet by mail.

Incomplete application packets will not be processed.

Applications for financial assistance will be accepted prior to the beginning of each Fall/Spring semester (quarter system as appropriate). Students shall apply for total funds required to complete studies. Students will only be awarded one loan. If additional funds are needed, students may submit a written request to the Loan Advisory Committee to increase the loan amount. The request should include the reasons and purpose of the increase. Granting of the request will be at the discretion of the director of health. The new amount approved cannot exceed $10,000.

Upon receipt of complete application materials, a personal interview may be scheduled with the Loan Advisory Committee.

Applicants will be notified by mail of their acceptance or denial into the program.

Nursing Student Loan Program General Application Information and Instructions

SELECTION PROCESS

In addition to the minimum selection criteria, additional criteria may include:

1. Completeness of application packet

2. Personal Statement

3. Grade Point Average

4. Personal Interview

The department may disapprove the loan for any of the following reasons:

1. The applicant cannot meet certain personal credit requirements established by the Loan Advisory Committee.

2. The applicant's moral character is questionable as determined by the Loan Advisory Committee.

3. The applicant fails to meet other criteria deemed necessary by the Loan Advisory Committee in justifying or granting a loan.

Funds will be disbursed on a semester/quarter basis. Allocations will be made each semester/quarter to the loan beneficiary upon submission of:

1. Transcripts from the previous academic semester indicating that the loan recipient has a minimum GPA of 2.0 on a 4.0 scale).

2. Letter from the school of nursing confirming the recipient's successful completion of the previous semester.

REPAYMENT OBLIGATION

Funding received through this program shall be repaid. By accepting this funding, the recipient agrees to become employed full-time as a licensed registered nurse or directly providing or supervising clinical care with an institution or organization in Hawaii for a rninimum of three years. The recipient shall begin employment within ninety days of taking the NCLEX

For each twelve months of continuous service as noted above, 20 per cent of the obligation will be "forgiven" or cancelled. After working the required three years, sixty per cent of the obligation will be forgiven. To forgive the entire obligation through employment shall require five years. There will be no credit given for partial years worked. If recipient requires time off from work due to temporary disability insurance/ workers compensation, personal emergency (limited to six months), or involuntary military duty, the repayment period will be deferred and added to the end of the loan repayment period.

Repayments of loans shall commence immediately under any of the following conditions:

1. The recipient withdraws from nursing studies prior to graduation or converts to part-time status.

2. The recipient graduates but does seek employment.

3. The recipient graduates but is employed in the State in a profession other than as a registered nurse.

4. The recipient graduates and becomes employed in any field outside the State of Hawaii

Interest will start from the time employment ends or is reduced. Each loan shall bear a simple interest rate not to exceed five per cent per year. If a recipient fails to meet repayment obligations, the recipient's credit rating may be affected and the Department of Health reserves the right to take legal action as necessary to recover funds.

OTHER INFORMATION

Funds will be disbursed to the recipient after they have signed a Letter of Understanding, which reiterates their obligations under this program.

The recipient will be responsible for having their school's Registrar complete and return a confirmation of full-time enrollment, major and GPA each semester.

Loans are awarded for the duration of the studies. However, if a recipient fails to maintain full-time status, minimum GPA or major in Nursing after any semester, funds will not be provided and repayment will be due immediately.

Deferment of repayment is available if the recipient becomes temporarily disabled, as certified by a licensed physician.

Haw. Code R. tit. 11, subtit. 1, ch. 351, Application for Nursing Student Loan Program