Trish Dominic Physician Loan Repayment Program Application Form share First Name * Middle Name * Last Name * Gender * Male Female Prefer not to say Are you of Hispanic, Latino, or Spanish origin? * No, not of Hispanic, Latino, or Spanish Origin Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin Race * Please select all that apply Prefer not to say White Black or African American American Indian or Alaska Native Chinese Vietnamese Native Hawaiian Filipino Korean Samoan Asian Indian Japanese Chamorro Other Asian Other Pacific Islander Other race Current Mailing Address Street Address * City * State * Zip Code * County * Permanent Mailing Address Same as Current Mailing Address Street Address * City * State * Zip Code * County * Other Contact Information Primary Phone * Secondary Phone * Email Address * Additional Email Address Medical School Medical School * The institution from which you received your medical degree Graduation Year * The year you received your medical degree --Select-- 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Degree * MD DO Residency Residency program * Include institutional name Year of completion * --Select-- 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 City * State * Residency Program Type * Internal Medicine Pediatrics Internal Medicine/Pediatrics “Med-Peds” Other Fellowship Fellowship program * Include institutional name Year of completion * --Select-- 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 City * State * Fellowship Program Type * Hematology Oncology Hematology/Oncology Other Additional Post-Residency Training or additional Fellowship Training Program Include institutional name Year of completion --Select-- 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 City State Description NPI Number * Please provide your NPI number as it is recorded on the NPPES NPI Registry Georgia Hemophilia Treatment Center Practice Location HTC Name * Street Address * City * State * Zip Code * County * Practice Phone Number * What month and year did you start at the HTC listed above? Month * --Select-- January February March April May June July August September October November December Year * --Select-- 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Contact at Institution to verify employment status Name * Email * Phone number (work) * Provide estimates of total anticipated/outstanding educational debt. If you are considered for receiving an award from this program, you may be asked to provide additional details. For more detail, contact TDLoan@hog.org Undergraduate Educational Debt * Please include Parent PLUS loans that were obtained by others on your behalf Medical Educational Debt * Other Educational Debt * Total * Provide estimates of PAID educational debt. If you are considered for receiving an award from this program, you may be asked to provide additional details. For more detail, contact TDLoan@hog.org Undergraduate Educational Debt * Please include Parent PLUS loans that were obtained by others on your behalf Medical Educational Debt * Other Educational Debt * Total * Have you received funds from any of the following sources? * An award from the Trish Dominic Loan Repayment Assistance Program Awards from other loan repayment assistance programs Awards from loan forgiveness programs such as, but not limited to, Public Service Loan Forgiveness (PSLF) Program Merit-based grants/scholarship/aid Need-based grants/scholarship/aid Family income Family savings Other Total Are there conditional aspects of any of the sources? For example: [1] "This award requires me to practice hematology at a HTC in Georgia for two years." [2] "Because of their support, I have promised to have my parents live with me when they reach retirement age." [3] "I promised to pay my aunt back within 10 years of completing medical school." * Personal Statement * Please describe your interest in and commitment to caring for individuals with bleeding disorders. In less than 1,500 words, discuss the experiences, mentors, patients, educational opportunities, research activities, or personal influences that have shaped your decision to pursue a career in bleeding disorders care. Your statement should address the following: Motivation and Commitment What inspired your interest in bleeding disorders care? How have your experiences demonstrated a commitment to serving individuals and families affected by bleeding disorders? Career Goals Describe your short-term and long-term career plans. Explain how practicing at a Hemophilia Treatment Center (HTC) in Georgia aligns with your professional goals and how you intend to contribute to the bleeding disorders community. Program Selection Criteria Discuss at least two of the following factors that are relevant to your current circumstances, professional interests, or future plans: Leadership, advocacy, education, research, community engagement, or other commitments related to bleeding disorders. Commitment to practicing at a Georgia HTC and improving access to specialized care. Interest in serving patients in medically underserved, rural, or non-metropolitan communities. Commitment to working within nonprofit, academic, public service, or mission-driven healthcare organizations. Educational debt burden or other significant financial obligations. Please provide specific examples whenever possible and describe how participation in the Trish Dominic Physician Loan Repayment Assistance Program will help you achieve your professional goals while strengthening access to bleeding disorders care in Georgia. Please attach your Resume or CV as a PDF. Label the file as LastnameFirstname_DominicCV.pdf or LastnameFirstnameMiddleinitial_DominicCV.pdf For example, Henry J. Simpson would submit a file named ‘SimpsonHenryJ_DominicCV.pdf * Certification and Attestation I certify that all information and supporting documentation provided in this application are true, accurate, and complete to the best of my knowledge and belief. I understand that any false, misleading, or omitted information may result in the denial, withdrawal, or repayment of loan assistance awarded through this program. By signing below, I affirm that I have read and understand the program requirements and agree to comply with all applicable terms and conditions. Applicant signature * Printed Name * Date * * Required Fields
