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VMLRP Applicant Information Form (NIFA-01-10)

The Applicant Information Form collects relevant identifying, contact, and employment information from the applicant. 


Section 1 – Indicate the application type by checking new or renewal. Provide your full legal name, including other legal names you may have used in the past. You also need to enter the five-digit Shortage Identification Code for the shortage situation you intend to fill. The code entered on this form must match the code entered on the Intent of Employment form (NIFA-07-10). You may apply to fill only ONE shortage situation. Indicate the shortage type as Type I, Type II, or Type III as stated on the shortage nomination form you are applying. 

Section 2 – Provide your full residential address, including apartment number if applicable. Enter your home phone number, including area code. Enter your fax number (optional). Most communication by VMLRP staff is done by email, so be sure to provide a valid email address that you check frequently (at least once a week).

Section 3 – Provide your current employment contact information, if applicable. Indicate your position title, name of organization/practice, name of division/school, or department/section, if applicable. Please include employment address, which may include any apartment, room, or mail stop numbers. Also, enter your work phone number and email address. Please designate if it is best to reach you at your residential or work/school contact information. 

Section 4 – Provide details on your educational and practice experience, if applicable. Information covered includes education, training, practice experience, and licensing. If any line does not apply to you, write “NA” (for “not applicable”) on that line and go on to the next line. If any item is pending due to recent graduation, pending license or accreditation results, please write pending on that line and go on to the next line.

Section 5 – Provide information on any existing service obligations you might have. A service obligation is defined as required employment for a period of time in exchange for a loan-related benefit (e.g., repayment or forgiveness). If you have an existing service obligation as defined here, check YES and complete this section. If you do not have an existing service obligation, check NO and go to Section 6.

Section 6 – Providing information in this section is completely voluntary. Failure to answer these questions will have no effect on your application.

Section 7 – Certify whether you have a judgment lien against your property or are delinquent on any debt to the United States by placing a checkmark in the appropriate boxes. Also, certify the accuracy of the information provided on this form by checking the box in the second paragraph.

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