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, ie-$30,000 total, includes $20,000 loan repayment and $10,000

sign-on bonus.

Section 2: Clinic Information

Section 3: Provider Vacancy Details

Section 3: Financial Assistance Eligibility

Section 4: Prior Assistance

Section 5: Additional Information