EFN/FADHPS/PCL Programs
Practice Certification Form

If you choose not to submit this application electronically

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As an EFN and FADHPS recipient you are required to practice primary health care for 5 years after completion or residency. As a PCL recipient you are required to practice primary health care until your loan is repaid in full. * Required Fields
 

* Last Name:

    

* First Name:

    
* Year Graduated from OUCOM:      

 

* Home Address Line 1:

    

Address Line 2:

    

* City/State:

    

* Zip Code (no hyphens):

    

 

Phone Numbers:
 

* Work:

    

* Home:

    

Cell:

    

Beeper:

    
   

* E-mail Address:

    

 

* I received :

EFN

    
 

FADHPS

    
 

PCL

    
 
* and am notifying the school of my:        activities

 
* This is to certify that my current practice status is what I have checked below and I plan to remain in this practice from July 1, 2007 through June 30, 2008.
 

Family Medicine

    
 

General Pediatrics

    
 

Osteopathic General Practice

    
 

General Internal Medicine

    
 

Preventive Medicine

    
 

Other

    
 

 
Comments/Questions/Special Circumstances:  
 
I understand that by entering my first and last name initials (e.g.,  jb for John Brennan) in this box and submitting this application electronically, I am agreeing to all the information requested above and that I am in compliance with the obligations specified in my EFN/FADHPS agreements(s) and/or PCL promissory note for primary health care service.
 

Warning: Any person who knowingly makes a false statement or misrepresentation on this form is subject to penalties which may include fines and imprisonment under Federal Statute.
 
When you click on  submit a confirmation page containing all the information you entered above will be generated. A printed copy of the confirmation page should be retained for your own records.