Review the eligibility requirements and allowable funding uses prior to completing this application. Applications that do not meet the initial eligibility requirements will be denied.  

Complete the following application and submit for review and consideration. The decision- making process may take up to 30 days from the application submission. 

Decisions will be communicated in writing to the contact person on the application.

Section 1: Clinic Demographics

Request Details: Include the total request amount and a detailed plan for the requested amount (e.g. $25,000 total for APP, includes $15,000 loan repayment and $10,000 sign-on bonus).

Note the following request limits for allowable funding uses:

(You can review the eligibility criteria and allowable/disallowable funding uses here)

Up to $100,000 for MD/DO providers

Up to $25,000 for APP providers

Reduced funding packages for part-time providers: $60,000 MD/DO, $15,000 APP

One provider per request per clinic per year

Section 2: Clinic Information

Section 3: Provider Vacancy Details

Section 3: Financial Assistance Eligibility

Section 4: Prior Assistance

Section 5: Additional Information