Hawaii Administrative Rules › Title 11 - DEPARTMENT OF HEALTH › Subtitle 1 - GENERAL DEPARTMENTAL PROVISIONS › Chapter 351 - NURSING STUDENT LOAN PROGRAM › Application for Nursing Student Loan Program

Current through June, 2024
Department of Health State of Hawai'i
APPLICATION FOR NURSING STUDENT LOAN
				  PROGRAM
Please Print or Type
Section
				I: PERSONAL DATA
Name__________________________________________________________
(Last) (First) (Middle)
Address_________________________________________________________
(City) (State) (Zip Code)
Phone ( ) ___-____ Social Security
				  No._____-_____-_____
If you are NOT a U.S. citizen, are you eligible for
				  employment in the U.S.? * Yes* No
Name and address of nearest relative NOT residing with
				  you
Name____________________________Relationship_____________________
Address___________________________________Phone ( )
				  ____-_____
Please provide one personal and one professional
				  reference
Personal Reference (Do NOT list a relative)
Name____________________________Relationship_____________________
Address____________________________________Phone ( )
				  _____-_____
Professional Reference (Do NOT list a supervisor)
Name____________________________Relationship_____________________
Address____________________________________Phone ( )
				  _____-_____
APPLICATION FOR NURSING STUDENT LOAN PROGRAM
Section II: EDUCATIONAL INFORMATION
NAME AND LOCATION SCHOOLS ATTENDED
YEARS ATTNDED
MAJOR
DEGREE/ DIPLOMA
HIGH SCHOOL
COLLEGE
OTHER SCHOOLING
Name of Nursing School
				  Attending_______________________________________
Status: * Accepted into Nursing Program
* Not accepted into Nursing Program
* Pending
				  (explain)____________________________________________
Enrollment
				  Date_____________________________________________________
Anticipated Graduation
				  Date___________________________________________
Grade Point Average (based on 4.0
				  scale)__________________________________
Degree
				  Pursued_____________________________________________________
APPLICATION FOR NURSING STUDENT LOAN
				  PROGRAM
Section III: EMPLOYMENT
				  INFORMATION
Please begin with your most recent employment
Employer__________________________________Phone No. ( )
				  _____-_______
Address__________________________________________________________
Name and Title of
				  Supervisor__________________________________________
Your
				  Title________________________________________________________
From_________________To_________________* Full Time * Part
				  Time
Employer__________________________________Phone No. ( )
				  _____-_______
Address__________________________________________________________
Name and Title of
				  Supervisor__________________________________________
Your
				  Title________________________________________________________
From_________________To_________________* Full Time * Part
				  Time
Employer__________________________________Phone No. ( )
				  _____-_______
Address__________________________________________________________
Name and Title of
				  Supervisor__________________________________________
Your
				  Title________________________________________________________
From_________________To_________________* Full Time * Part
				  Time
Employer__________________________________Phone No. ( )
				  _____-_______
Address__________________________________________________________
Name and Title of
				  Supervisor__________________________________________
Your
				  Title________________________________________________________
From_________________To_________________* Full Time * Part
				  Time
APPLICATION FOR NURSING STUDENT LOAN
				  PROGRAM
Section IV: FINANCIAL
				  INFORMATION
For what funding you are applying? (Maximum $10,000 per
				  year)
* Tuition
* Expenses
* Tuition and Expenses
Please complete the following information
Total annual gross income $____________
Total monthly expenses $____________
Please summarize your monthly financial needs and expenses
				  on the reverse side of this page
Indicate entire loan amount requested by semester or
				  quarter
Semester/Quarter
Tuition
Other Expenses
Total Expenses
TOTAL
Other financial assistance information
INSTITUTION
TYPE ASSISTANCE
ASSISTANCE
APPLIED FOR
RECEIVING
APPLICATION FOR NURSING STUDENT LOAN
				  PROGRAM
Section V: STATEMENT OF PERSONAL AND
				  PROFESSIONAL GOALS
Discuss your reasons for applying for this loan. Include
				  information on your background; school and community activities in which you
				  have participated; awards and special recognition you have received; your
				  hobbies and interests; the reasons you have for becoming a nurse; and your
				  future career goals. Attach additional page(s) if necessary.
APPLICATION FOR NURSING STUDENT LOAN
				  PROGRAM
Section VI:
I certify that the information provided in this application
				  is truthful.
I have read the Nursing Student Loan Program General
				  Application Information and Instructions and understand and accept the
				  employment/repayment obligations associated with participating in this loan
				  program.
____________________________________________________________________
Applicants Signature Date
The following shall be submitted together:
1. Completed application
2. Statement of Personal and Professional
				Goals
3. Copies of all high school
				and college transcription
4.
				Verification of grade point average
5. Notarized Letter of Intent to work as a
				registered nurse with an institution or organization providing direct clinical
				care in Hawai'i for a minimum of three year after obtaining a license under
				chapter
				457, the
				Hawai'i Revised Statutes
Application and required attachments shall be submitted
				  to:
Department of Health
State of Hawai'i
Division of Community Hospitals
1270 Queen Emma Street, Suite 1200
ATTN: NURSING STUDENT LOAN PROGRAM
Honolulu, Hawaii 96813
APPLICATION FOR NURSING STUDENT LOAN APPLICATION
NOTICE OF INTENT
Name_______________________________________________________
Social Security Number ______-______-_______
Total Repayment (Amount Requesting) Obligation
				  $______________
I agree to work as a registered nurse or as a nurse
				  practitioner with an institution or organization providing direct clinical care
				  in Hawai'i for a minimum of three years of obtaining a license pursuant to
				  chapter
				  457 of
				  the Hawai'i ] Statutes.
I,_________________________________________________, certify
				  that I am a student registered in a full-tin accredited specialized nursing
				  educational program as defined by an accredited degree-granting university,
				  college nursing institution in Hawai'i or the mainland and meet the eligibility
				  requirements to obtain a loan under the Nursing Student Loan Program. I have
				  read and agree to comply with the terms outlined in the Nursing Student Loan
				  Program General Application Information and Instructions. I understand that if
				  awarded a loan, the loan amount will be paid to me each semester upon
				  submission of the following:
1. Transcripts from the previous academic
				semester indicating a minimum GPA of 2.0 (based on a 4.0 scale).
2. A letter from the school of nursing
				confirming successful completion of the previous semester.
I understand that upon graduation, I must obtain employment
				  as a registered nurse or a nurse practitioner in Hawai'i for a minimum of three
				  years immediately following obtaining a license under chapter 457, Hawai'i
				  Revised Statutes. I understand that for each full year (12 months) of
				  continuous employment as outlined above, twenty per cent of my total repayment
				  obligation will be forgiven. To cancel the entire obligation shall require five
				  years of employment.
I understand that any leaves of absence will cause the
				  fulfillment date of my obligation to be adjusted. I also understand that the
				  repayment obligation amount is due immediately upon any of the following
				  conditions:
1. I withdraw
				from nursing studies prior to graduation or convert to part-time
				status.
2. I graduate but do not
				seek employment.
3. I graduate and
				become licensed but I become employed in the State in a profession other than
				as a registered nurse.
4. I
				graduate and become employed in any field outside the State of Hawai'i
______________________________________________________________
(Name)
______________________________________________________________
(Signature) (Date)
Subscribed and sworn to before me this ____day
				  of_____,199___.
Notary Public, State of Hawai'i
My commission expires:
STATE OF HAWAI'I
DEPARTMENT OF HEALTH
NURSING STUDENT LOAN
				  PROGRAM
GENERAL APPLICATION INFORMATION AND
				  INSTRUCTIONS
OVERVIEW
Nursing students may receive financial assistance through a
				  restricted loan program as they pursue an accredited specialized nursing
				  education program with an accredited degree-granting university, college, or
				  nursing institution in the State of Hawaii In the event that no accredited
				  specialized nursing educational programs are available in the State of Hawai'i,
				  consideration for loan approval with an accredited degree-granting or
				  certificate-granting university, college, or nursing institution outside the
				  State of Hawai'i may be given The program will run from July 1,1991 to June
				  30,1995, or until all available funds are expended, whichever comes first Loan
				  recipients are expected to repay their loans by June 30, 2000.
The Department of Health, State of Hawai'i provides services
				  and opportunities to take part in its programs and activities without regard to
				  race, color, national origin, age, disability, or sexual orientation.
FUNDING AVAILABLE
Funding under this loan program is limited to a maximum of
				  $10,000 per student per academic year, not to exceed five years.
Low interest loans are available to persons who are studying
				  to become licensed registered nurses and who intend to work in Hawai'i. The
				  loan amounts shall be used for:
1.
				Payment of tuition.
2. Other
				necessary financial assistance in connection with obtaining a degree or
				certificate from an accredited degree-granting university, college, or nursing
				institution in Hawai'i.
3.
				"Matching funds" to secure grants from other sources.
MINIMUM SELECTION
				  CRITERIA
Applicants shall:
1. Be a student pursuing a career as a
				registered nurse.
2. Have been
				accepted and classified as a full-time nursing student by the applicant's
				respective school.
3. Have been a
				Hawai'i resident for at least one year prior to the date the applicant applies
				for a loan.
4. Have not previously
				graduated from a similar nursing program and is not repeating any
				nursing-related courses.
5. Intend
				to become licensed and obtain employment as a registered nurse directly
				providing or supervising clinical care immediately upon graduation and work in
				Hawaii for a minimum of three years.
APPLICATION PROCESS
Applicants shall submit:
1. Completed "Application for Nursing Student
				Loan Program."
2. A confirmation
				from an accredited degree-granting university, college, or nursing institution
				confirming that the applicant is either a current student or will be commencing
				studies in the upcoming academic semester.
3. Official copies of college transcripts.
				Applicants who have not previously attended college shall submit high school
				transcripts.
4. A written essay on
				the applicant's personal and professional goals using the form provided by the
				department.
5. A written notarized
				form provided by the department, which indicates the applicant intends to work
				as a registered nurse in Hawaii for a minimum of three years immediately
				following obtaining a license under chapter 457, Hawai'i Revised Statutes.
At the discretion of the Loan Advisory Committee, applicants
				  may be subject to a credit verification and will be notified of this check when
				  applying for the loan.
Applications and required attachments listed above shall be
				  submitted together to:
Department of Health
State of Hawai'i
Division of Community Hospitals
1270 Queen Emma Street, Suite 1200
ATTN: NURSING STUDENT LOAN PROGRAM
Honolulu, Hawai'i 96813
Applications may be obtained from the Office of the Director
				  of the Department of Health at 1250 Punchbowl Street, 3rd Floor. Applicants may
				  also call 586-3991 to receive a packet by mail.
Incomplete application packets will not be processed.
Applications for financial assistance will be accepted prior
				  to the beginning of each Fall/Spring semester (quarter system as appropriate).
				  Students shall apply for total funds required to complete studies. Students
				  will only be awarded one loan. If additional funds are needed, students may
				  submit a written request to the Loan Advisory Committee to increase the loan
				  amount. The request should include the reasons and purpose of the increase.
				  Granting of the request will be at the discretion of the director of health.
				  The new amount approved cannot exceed $10,000.
Upon receipt of complete application materials, a personal
				  interview may be scheduled with the Loan Advisory Committee.
Applicants will be notified by mail of their acceptance or
				  denial into the program.
Nursing Student Loan Program General Application Information
				  and Instructions
SELECTION PROCESS
In addition to the minimum selection criteria, additional
				  criteria may include:
1. Completeness
				of application packet
2. Personal
				Statement
3. Grade Point
				Average
4. Personal Interview
The department may disapprove the loan for any of the
				  following reasons:
1. The
				applicant cannot meet certain personal credit requirements established by the
				Loan Advisory Committee.
2. The
				applicant's moral character is questionable as determined by the Loan Advisory
				Committee.
3. The applicant fails
				to meet other criteria deemed necessary by the Loan Advisory Committee in
				justifying or granting a loan.
Funds will be disbursed on a semester/quarter basis.
				  Allocations will be made each semester/quarter to the loan beneficiary upon
				  submission of:
1.
				Transcripts from the previous academic semester indicating that the loan
				recipient has a minimum GPA of 2.0 on a 4.0 scale).
2. Letter from the school of nursing
				confirming the recipient's successful completion of the previous
				semester.
REPAYMENT OBLIGATION
Funding received through this program shall be repaid. By
				  accepting this funding, the recipient agrees to become employed full-time as a
				  licensed registered nurse or directly providing or supervising clinical care
				  with an institution or organization in Hawaii for a rninimum of three years.
				  The recipient shall begin employment within ninety days of taking the
				  NCLEX
For each twelve months of continuous service as noted above,
				  20 per cent of the obligation will be "forgiven" or cancelled. After working
				  the required three years, sixty per cent of the obligation will be forgiven. To
				  forgive the entire obligation through employment shall require five years.
				  There will be no credit given for partial years worked. If recipient requires
				  time off from work due to temporary disability insurance/ workers compensation,
				  personal emergency (limited to six months), or involuntary military duty, the
				  repayment period will be deferred and added to the end of the loan repayment
				  period.
Repayments of loans shall commence immediately under any of
				  the following conditions:
1. The
				recipient withdraws from nursing studies prior to graduation or converts to
				part-time status.
2. The recipient
				graduates but does seek employment.
3. The recipient graduates but is employed in
				the State in a profession other than as a registered nurse.
4. The recipient graduates and becomes
				employed in any field outside the State of Hawaii
Interest will start from the time employment ends or is
				  reduced. Each loan shall bear a simple interest rate not to exceed five per
				  cent per year. If a recipient fails to meet repayment obligations, the
				  recipient's credit rating may be affected and the Department of Health reserves
				  the right to take legal action as necessary to recover funds.