Student Loan Repayment Grant Program Application

Thank you for expressing interest in the CDA Foundation and its grant giving program. We appreciate you applying for our services which are available to benefit people who want to improve the oral health of all Californians.

Prior to beginning the online application process, please scan the following supporting documents and have them ready to upload as attachments (Word, Excel, PDF, etc.) to this application when prompted to do so later:

Current lending institution statement(s).

During this application process, you will need to answer the questions by typing text, checking boxes/buttons, and where prompted, upload/download documents as attachments to this online application. All requested file uploads and downloads are required to complete your application. Once we have received your application, an automated receipt confirmation will be sent to you at the e-mail address provided below. Good luck!

Submission Criteria

Complete online application, attaching all supporting documents, and submit online.
Complete only sections I-III of the loan and work site verification forms and submit both online with your application. CDA Foundation will obtain the lender and work site information necessary to complete the rest of the form.
Approval from CDA Foundation staff is required prior to accepting e-mailed applications. If you are experiencing difficulties submitting the online application, please contact the CDA Foundation staff via e-mail at jolene.murray@cda.org to request an alternative submission method and a Word document of the grant application will be sent to you for completion.

Incomplete applications are ineligible to receive an award.

Light Purple Shaded Areas are Required Fields

I. Personal Data

Applicant Name First Name Last Name

Home Address Street Street (cont.) City State Zip

Day Phone Evening Phone E-mail Address Date of Birth

Are you a United States citizen?

Yes No

If no, click here to upload documentation of your naturalization or proof of US residency.

Upload File:

Please keep individual attachments under 300k. Please click here for scanning tips.

Do you have an existing service obligation?

Yes No

If yes, include any outstanding contractual obligation for health professional service to the Federal Government (e.g., an active or reserve military obligation) or a State or other entity (e.g., State loan repayment program or scholarship program) and describe the status of it .

Maximum 500 characters. Characters used: 0.

Please describe if you have ever been, or are currently in default or have judgment liens for any debt including, but not limited to, taxes and education assistance programs. If not, please enter none.

Maximum 500 characters. Characters used: 0.

The CDA Foundation Student Loan Repayment Program seeks to provide grants to individuals who are likely to remain in a dental health professional shortage area (DHPSA) beyond the terms of the service contract. Research has shown that health professionals from certain backgrounds and areas are more likely to serve in those areas. Preferences in grant awards will be given to eligible recipients whom can check any of the below.

Please check all items that apply to you and provide a description.

a. I have a disadvantaged background with economic, social or other obstacles.

b. I lived in a rural, highly minority or Health Professional Shortage Area (HPSA) community for an extended period of time, particularly from birth to age 18.

c. I have demonstrated an initiative to develop cultural and linguistic competencies reflecting one or more diverse socioeconomic or ethnic communities throughout California.

d. I have previously completed a successful contract under a State, Federal or private loan reduction program.

*You must provide a description for each of the items checked above, or they will not be considered:

Maximum 2,500 characters. Characters used: 0.

Please share with the review committee your career goals & how this award will assist you in reaching them.

Maximum 2,500 characters. Characters used: 0.

II. Gender/Race/Ethnicity Data

Male Female

American Indian/Alaskan Native

Black/African American

Native Hawaiian

Asian (all)

Pacific Islander

Hispanic/Latino

Caucasian

Other (specify)

III. Health Professional Education

Will you be graduating from an American Dental Association accredited California dental school or a specialty program within three months or have you graduated within the last three years?

Yes No

School or Specialty Program (if specialty, then enter both school and program names) Date of Graduation (if specialty, then enter this date of graduation)

What credential will/have you earn(ed)?

DDS

DMD

City (if specialty, then enter the specialty program informaion) State Zip Code Postgraduate Training: (i.e. externship, residency, etc.)

Specialty Training?

Yes (specify) No

Are you currently licensed in CA?

Yes No

If yes, CA License Number: If no, when do you plan to be licensed in CA? (date boards to be taken):

IV. Work Site

1. Please indicate below whether you are willing and able to sign a binding contract to serve a minimum of three years (36 months) in the following areas:

a. A California Dental Health Professional Shortage Area (DHPSA)?

Yes No

b. An area of the state where unmet priority needs for dentists exist as determined by the Health Manpower Policy Commission?

Yes No

c. An under served work site as determined by the CDA Foundation Board of Directors.

Yes No

2. Have you identified or secured employment with an eligible work site(s)?

Yes No

I agree to provide a total of 30 hours per week (minimum) of direct patient care at the following work site(s):

Work Site Name Number of hours agreed to provide direct patient care:

A. Work Site Address Street Street (cont.) City State Zip

Work Site Director's Name: Work Site Director's Title: Work Site Telephone No.:

B. Work Site

Work Site Name: Number of hours agreed to provide direct patient care:

Work Site Address Street Street (cont.) City State Zip

Work Site Director's Name: Work Site Director's Title: Work Site Telephone No.:

C. Work Site

Work Site Name: Number of hours agreed to provide direct patient care:

Work Site Address Street Street (cont.) City State Zip

Work Site Director's Name: Work Site Director's Title: Work Site Telephone No.:

Work Site Verification Form

Please download and complete the required work site verification form(s) below:

Download the work site verification form

Please upload your completed work site verification form(s) here:

Upload File:

Please keep individual attachments under 300k. Please click here for scanning tips.

V. Educational Debt

You must attach a current loan statement file for each lending institution you have a loan with. Each statement must contain your name, account number, the principle and interest amounts and/or the payoff balance.

Upload current loan statemen #1.

Upload File:

Please keep individual attachments under 300k. Please click here for scanning tips.

Upload current loan statement #2.

Upload File:

Please keep individual attachments under 300k. Please click here for scanning tips.

Upload current loan statement #3.

Upload File:

Please keep individual attachments under 300k. Please click here for scanning tips.

Upload current loan statement #4.

Upload File:

Please keep individual attachments under 300k. Please click here for scanning tips.

Upload current loan statement #5.

Upload File:

Please keep individual attachments under 300k. Please click here for scanning tips.

Complete the student loan verification form. (Download and fill in the student loan verification form below).

Download the student loan verification form

Please upload your completed student loan verification form here:

Upload File:

Please keep individual attachments under 300k. Please click here for scanning tips.

VI. Certification and Signature

Certification

I acknowledge that the decisions of the Grant Selection Committee and the CDA Foundation are final and that this is a competitive selection process. I certify that the information provided is complete and accurate to the best of my knowledge. I understand that this application may be denied or withdrawn if it is incomplete and/or if any information reported is found to be intentionally misleading, inaccurate or fraudulent.

I authorize the CDA Foundation to use my name and/or photo for the purpose of community and public relations.

Electronic Signature (Required)

Please check the electronic signature button, type in your first and last name in the space provided, and click the button on this page labeled "Submit" to certify that all statements made in this application and its attachments are complete and accurate to the best of your knowledge, and to authorize the CDA Foundation to verify the information provided in this application.

Electronic signature (type full name)

By submitting your application, you certify that all statements made in this application and its attachments are complete and accurate, and you understand that falsification will disqualify your application.

Please type in the characters you see in the previous image here:

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Student Loan Repayment Grant Program Application

I. Personal Data

II. Gender/Race/Ethnicity Data

III. Health Professional Education

IV. Work Site

1. Please indicate below whether you are willing and able to sign a binding contract to serve a minimum of three years (36 months) in the following areas:

I agree to provide a total of 30 hours per week (minimum) of direct patient care at the following work site(s):

B. Work Site

C. Work Site

Work Site Verification Form

V. Educational Debt

Upload current loan statemen #1.

Upload current loan statement #2.

Upload current loan statement #3.

Upload current loan statement #4.

Upload current loan statement #5.

Please upload your completed student loan verification form here:

VI. Certification and Signature

Certification

Electronic Signature (Required)

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