POST-RESIDENCY CERTIFICATION FORM FOR PRIMARY CARE LOAN RECIPIENTS
Saint Louis University Phone: 314-977-2407
Student Loans Fax: 314-977-3437
One Grand Blvd Email: kupferme@slu.edu
DuBourg Hall, Rm 2
St. Louis, MO 63103
As a Primary Care Loan recipient you are required to practice primary health care until your loan is repaid
in full. Please complete and return this form to the address shown above.
Part I: Borrower Information (Please Print)
Name: __________________________________________________ SSN#: ______________________
(Last, First, MI)
Home Address: _________________________________________________________________________
Street City State Zip Code
Home Phone Number: __________________________ Email Address: ___________________________
Employer Name: __________________________________ Employer Phone: ____________________
Employer Address: ______________________________________________________________________
Street City State Zip Code
Part II: Service Obligation Acceptable Practice Activities (please check your current practice):
Primary Care Clinical Practice Urgent Care
Clinical Preventive Medicine Sports Medicine
Occupational Medicine Training for Primary Care Faculty
Public Health Training for Public Policy
Senior/Chief Resident in Primary Care Masters in Public Health
Faculty, Administrator or Policy Maker in Primary Care Public Policy Fellowship
Geriatrics Faculty Development Training
Adolescent Medicine Primary Care Fellowship
Adolescent Pediatrics Hospitalist
I am no longer practicing Primary Care
Comments:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Part III: Borrower’s Certification
I certify the information contained in this document is accurate and that I am in compliance with the primary care
obligations specified in the primary care loan note signed at the time of disbursement. Falsification of certification
will result in implementing penalties retroactively, adjusting the repayment schedule from the date of non-
compliance. Interest penalties of 2%, 12%, or 18% will occur based on the penalty rate identified within the original
promissory note.
I understand I will be required to reaffirm my commitment on an annual basis until the loan is repaid.
_________________________________________________________________________________ ________________________
Borrower Signature Date
