DISADVANTAGED, NURSING, PRIMARY CARE,
HEALTH PROFESSIONS AND R.W. JOHNSON LOANS
REQUEST FOR DEFERMENT OF REPAYMENT
INSTRUCTION ON BACK OF FORM
PART I - GENERAL INFORMATION (To be completed by borrower)
Borrower is responsible to advise OHSU of current address!
NAME OF BORROWER
SOCIAL SECURITY NUMBER
NAME OF LENDING INSTITUTION
(College/University from which loan originated)
OREGON HEALTH & SCIENCE UNIVERSITY
SEND COMPLETED FORM TO:
Educational Computer Systems Inc.
181 Montour Run Road
Coraopolis, PA 15108-9408
CITY, STATE, ZIP
HOME PHONE NUMBER
WORK PHONE NUMBER
PART II - REQUEST FOR DEFERMENT OF REPAYMENT (To be completed by borrower)
A. Ceases to pursue the course of study at:
1. A school of medicine, osteopathy, dentistry, pharmacy, podiatric medicine, optometry, or veterinary medicine, but (1) re-enters the
same or another such school within the applicable grace period; or (2) engages in a full-time educational activity as defined by
regulations of the Secretary of Health and Human Services, with the intent to return to the school as a full-time student.
2. A school of nursing leading to a diploma or associate degree in nursing, a baccalaureate degree in nursing or an equivalent degree, or
to a graduate degree in nursing, but re-enters the same or another such school within the applicable grace period.
This is to certify that I was a full-time health professions or full or half-time nursing student at
from to pursuing a
course of study leading to a
B. Performs active duty as a member of a uniformed service or as a volunteer under the Peace Corps Act.
This is to certify that I was in the (enter Peace Corps or name of uniformed service)
from to _______________
C. (1) For Health Professions, Primary Care, Disadvantaged Students, and R.W. Johnson Student Loan
Pursues advanced professional training, including internships and residencies or participates in a fellowship training program or full-
time educational activity, as defined by regulations of the Secretary of Health and Human Services.
(2) For Nursing Student Loan Borrowers:
Pursues at least half-time or better course of study at a collegiate school of nursing leading to a baccalaureate degree in nursing or an
equivalent degree, or to a graduate degree in nursing, or is otherwise pursuing advanced professional training in nursing.
This is to certify that I was pursuing advanced professional training at
from to ________________
D. Pursues training as a nurse anesthetist at: ________________________________________________
SIGNATURE OF BORROWER: