DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service Commissioned Corps
ENGINEERING AND SCIENTIFIC CAREER CONTINUATION PAY (ESCCP) CONTRACT REQUEST
(Privacy Act Notice on Reverse)
IDENTIFICATION
NAME (Last, First, Middle Initial)
GRADE/RANK
PHS SERIAL NUMBER ORGANIZATION
DUTY PHONE NUMBER SSAN
DCP USE ONLY
DATE REC’D.
CT. DATE
EXP. DATE
CONDITIONS OF CONTRACT
In consideration of payment of the above requested special pay for which I qualify under 37 U.S.C. 315 and implementing policies
prescribed in INSTRUCTION 11, Subchapter CC22.2 of the Commissioned Corps Personnel Manual (CCPM), I hereby agree to the
following:
To remain on active duty in the PHS Commissioned Corps for 12 months from the effective date of this contract in a critical
shortage position.
A.
That the EFFECTIVE date will be the DATE THE NOTARIZED CONTRACT IS RECEIVED in the Compensation Branch (CB),
Division of Commissioned Personnel (DCP), except for conditions listed below:
B.
(a) Date I attain eligibility for ESCCP provided the completed contract is received in CB, DCP, within 60 days after I am
initially eligible, and the contract bears my signature, notarized within 30 days after I am initially eligible for ESCCP; or
(b) Date the completed contract is notarized if received in CB, DCP, within 60 days of the date of eligibility but has not been
notarized within 30 days of date of initial eligibility; or
(c) Later date, if eligible, specified by me, which is
,
.
(1) Effective date for initial contract will be the:
(a) Date following the date the preceding contract expires, provided the completed contract is received in CB,
DCP, within 60 days after the date of expiration of the previous contract, and the contract bears my
signature, notarized on or before the date following the date the preceding contract expired; or;
(b) Date the completed contract is notarized if received in CB, DCP, within 60 days after the date of expiration
of the previous contract, but has not been notarized on or before the date the previous contract expired.
(2) Effective date for subsequent contracts will be the:
If this contract is terminated prior to its expiration date for reasons other than as identified in F. below:C.
(1) I will be required to refund a pro rata portion of my payment received pursuant to this contract;
(3) Any amount which I am obligated to refund because this contract is terminated will be a debt due to the United States which I
hereby agree to pay in full as directed by the appropriate collections officials. In accordance with Treasury Fiscal
Requirements Manual (1 TFRM 6-8000, Cash Management), late charges may be assessed for payments made after the due
date on amounts owed to the U.S. Government.
(2) I will be divested of entitlements for travel and transportation allowances for myself and my dependents, shipment of
household goods, and transfer or use of, or payment for unused annual leave to my credit upon separation from PHS; and
That a period of Absence Without Leave (AWOL) shall not be credited toward fulfillment of the active-duty obligation incurred
pursuant to this contract and that the period of such active-duty obligation shall be extended by the number of days of AWOL.
D.
That the policies (INSTRUCTION 11, Subchapter CC22.2 of the CCPM) which implement the ESCCP provisions of 37 U.S.C. 315
are incorporated into and made part of this contract.
E.
That if I enter a long-term training program as defined in INSTRUCTION 1, Subchapter CC25.2 of the CCPM, this contract will be
terminated and I will repay an amount as specified in C.(1), above.
F.
That I am NOT ELIGIBLE for voluntary retirement for the duration of this contract.G.
CERTIFICATION
I certify that I understand and agree to the terms of this contract as stated above.
SIGNATURE
DATE
NOTARIZATION
Subscribed and sworn before me this day of
, A.D.,
.
at
(City) (State) (ZIPCode)
SIGNATURE
DATE COMMISSION EXPIRES
PHS-7015 (Rev. 09/01)
PSC Publishing Services (301) 443-6740
EF
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