SEND COMPLETED FORM TO:
Educational Computer Systems Inc.
181 Montour Run Road
Coraopolis, PA 15108-9408
1-888-549-3274
REQUEST FOR PARTIAL CANCELLATION
NURSE FACULTY LOAN PROGRAM
INSTRUCTIONS: A borrower under the Nurse Faculty Loan Program must file this form with the school of nursing which made the loan in order to claim entitlement
to loan cancellation for full-time nurse faculty employment pursuant to Section 846A of the Public Health Service Act, as amended by Public Law 107-205. The form
must be submitted for each complete year of full-time nurse faculty employment in a school of nursing. It is the responsibility of the borrower seeking cancellation to
(a) complete Part 1, (b) obtain certification by the employing agency, Part 2 and (c) forward the original and one copy to the lending school for cancellation of the loan
at the appropriate rate in lieu of payment. The lending school will complete Part 3, indicating the amount of cancellation earned (principal and interest), and return the
copy to the borrower making such request.
NAME & ADDRESS OF SCHOOL FROM WHICH LOAN WAS MADE:
OREGON HEALTH & SCIENCE UNIVERSITY
STUDENT LOANS AD208
3181 SW SAM JACKSON PARK ROAD
PORTLAND, OR 97239-3098
NAME & ADDRESS OF THE APPLICANT
PART l – COMPLETED BY BORROWE
R
I hereby apply for a
p
artial cancellation of my Nurse Faculty Loan in the appropriate amount of principal and interest, in accordance with Sections 846A of the Public Health Service Act, as
amended by Public Law 107-205, for one year of employment as a full-time nurse faculty.
NAME AND ADDRESS OF EMPLOYING AGENCY
PERIOD OF EMPLOYMENT:
BEGINNING (Month, Day, Year) END (Month, Day, Year)
SIGNATURE OF APPLICANT DATE
PART II – CERTIFICATION BY EMPLOYING AGENCY
I hereby certify that the above statements concerning full-time nurse faculty employment and the period of service are true and correct.
NAME OF APPLICANT
POSITION TITLE OF APPLICANT
NAME & ADDRESS OF EMPLOYING AGENCY
CHECK: ( ) PUBLIC ( ) Private for Profit ( ) Private not for Profit
SIGNATURE OF AUTHORIZED OFFICIAL
TITLE DATE
PART III – PARTIAL LOAN CANCELLATION (To be completed by Lending School)
The above named individual’s loan account has been credit3d for partial cancellation for full-time employment as nurse faculty in accordance with the Section 846A of the Public Health
Service Act, as amended, in the following amounts:
CANCELLATION RATE BY YEAR FOR EMPLOYMENT AS NURSE FACULTY:
( ) 1st Year – 20% ( ) 2nd Year – 20%
( ) 3rd Year – 20% ( ) 4th Year – 25%
CANCELLED:
PRINCIPAL AMOUNT INTEREST AMOUNT
SIGNATURE OF AUTHORIZING OFFICIAL – LENDING SCHOOL
TITLE
DATE
Print Form
EMPOYMENT CERTIFCATION FORM
(Applicant’s Name) ______________________________ entered into a contractual agreement with the
(Name of Lending School) Oregon Health & Science University
a participant in the Nurse Faculty Loan Program
(NFLP). This program requires the participant to be employed full-time as nurse faculty in a school of nursing for a
complete year in order to receive cancellation of his/her loan. Please complete the Employment Certification Form at the
bottom and return to the following:
Mail to:
Educational Computer Systems Inc.
C/O Oregon Health & Science University
181 Montour Run Road
Coraopolis, PA 15108-9408
1-888-549-3274
Keep a copy for your records
PART I: TO BE COMPLETED BY LOAN RECIPIENT
Name: ___________________________________________________
Permanent Address: ________________________________________ Phone # _______________
_________________________________________________________
Place of Employment: _______________________________________
Address: _________________________________________________
_________________________________________________________
Beginning Date of Employment as Nurse Faculty: Month __________ Day _____ Year ________
Position Title: ______________________________________________
I CERTIFY that I am employed full-time as Nurse Faculty in the above named School of Nursing, and all the information
is true and correct to the best of my knowledge. If I change employment status, I will notify Oregon Health & Science
University immediately.
Signature: ________________________________________ Date: ________________________
PART II: TO BE COMPLETED BY EMPLOYER
I CERTIFY that the statements above concerning service of the above named NFLP loan recipient as a full-time nurse
faculty are true and correct.
Name of Certifying Official: ________________________________________________________________
Title: ________________________ Phone Number: ___________________ Fax Number: ______________
Signature: _____________________________________________ Date: ______________________
If the above named participant has not
maintained faculty status during this period, please provide the date(s) and
explanation for the change.
Date(s): __________________________________
Explanation: ____________________________________________________________________________
_______________________________________________________________________________________
WARNING: ANY PERSON WHO KNOWLINGLY MAKES A FALSE STATEMENT OR MISREPRESENTATION OF THIS FORM IS
SUBJECT TO PENAL TIES WHICH MAY INCLUDE FINES AND IMPRISONMENT UNDER FEDERAL STATUTE.
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