Nurse Practitioner Education Grant 2014-2015 Application for Return-of-Service Grant For applicants graduating after July 1, 2014 Nurse Practitioners are an integral component of Manitoba s strategy to ensure all Manitobans have access to primary care. The Nurse Practitioner Education Grant (NPEG) Initiative was established in 2013 to encourage Nurse Practitioners to work in rural Manitoba after graduation. Recipients of the program will receive a conditional grant of $10,000 in exchange for agreement to return one year of service as a Nurse Practitioner in rural Manitoba. Before you start Information about the NPEG is available under Medical Grants at www.manitobastudentaid.ca Deadline: Your completed and signed application, along with any attachments, must be received by November 28, 2014. Applications missing information and/or attachments will not be processed until all information is received. In addition to your application, provide a letter of intent (maximum one page) outlining your commitment to rural communities and why you believe that you should be a recipient of the Nurse Practitioner Education Grant. Application Checklist Did you: Sign and date Section 500 (in ink) Provide banking information, sign and date Section 600 (in ink) Include a letter of intent (see above) Provide the contact information for TWO alternate contacts Include verification of your graduation such as a legible photocopy of your degree, or confirmation of your current enrollment Mail your completed Application and all attachments to: Medical Grants (Nurse Practitioner Education Grant) 401-1181 Portage Avenue Winnipeg, MB R3G 0T3 Phone: 204-945-8509 Available in alternate formats upon request. FOR OFFICE USE ONLY Name: page 1 of 7
SECTION 100 Your personal information Print clearly in ink. 101 Gender: Male Female 102 Last Name: 103 Legal First Name and Initial: 104 Social Insurance Number: 105 Date of Birth: 106 Home Telephone: 107 Cell Number: 108 Pager/Work Number: 109 Email Address: 110 Mailing Address: 111 City or Town: 112 Province: 113 Postal Code: 114 How did you hear about the Nurse Practitioner Education Grant? Educational Institution Friends or Family Advertisement Internet Other page 2 of 7
SECTION 200 Educational Information 201 Full name of your educational institution for 2014/2015: 202 Student Number: 203 As part of your program, have you completed a practicum in rural Manitoba? No Yes If Yes, where: 204 Education Status: Full-time Part-time 205 Select the box that describes your current situation: I graduated after July 1, 2014 Note: You must provide, together with this application, verification of your graduation in the form of the degree that was issued to you by the university. A legible photocopy of your degree will suffice. I expect to graduate by June 30, 2015 between July 1 and December 31, 2015 between January 1 and December 31, 2016 after January 1, 2017 Note: You must provide confirmation of your enrollment after your start date. page 3 of 7
SECTION 300 Employment Information Have you previously entered into any signed or oral contract(s) or commitment(s) for return-of-service as a Nurse Practitioner, with the Government of Manitoba or any other provincial or territorial government, the Government of Canada, any local/municipal government, health authority, or other organizations or funders? 301 Yes - Go to 302 No - Go to 303 302 Provide the following information: The name of the organization and date signed Return of service duration Location regarding such contract(s) The name of the organization and date signed Return of service duration Location regarding such contract(s) 303 Have you worked as a nurse in rural Manitoba? No Yes For how many years? 304 Have you secured employment as a Nurse Practitioner after graduation? No Yes If yes, where: page 4 of 7
SECTION 400 Alternate Contacts Alternate Contacts may be used to assist the program administrators in contacting you. Please provide 2 contacts with two different addresses and phone numbers other than yours: First Alternate Contact 401 First Name: 402 Last Name: 403 Relationship: 404 Address: 405 City/Province: 406 Postal Code: 407 Phone Number: Second Alternate Contact 408 First Name: 409 Last Name: 410 Relationship: 411 Address: 412 City/Province: 413 Postal Code: 414 Phone Number: page 5 of 7
SECTION 500 Representation/Acknowledgment/Authorization/Declaration I hereby declare that: All information provided on and/or with this application is complete, accurate, and true in every respect. I will not and have not received financial assistance from any other province, government, country, health authority, or funder in return for which I agree to provide a return-of-service other than reported in Section 300. I hereby acknowledge that: All personal information provided on this Application for the NPEG is being collected by Manitoba Education and Advanced Learning, Manitoba Student Aid, under the authority of the NPEG and will be used to determine whether I qualify for the purpose of receiving any financial assistance under the NPEG and to administer any financial assistance that I may be approved to receive under the NPEG. Such personal information is protected by Protection of Privacy provisions of The Freedom of Information and Protection of Privacy Act (Manitoba). If I have any questions regarding the collection of personal information, I can contact Manitoba Student Aid, 401-1181 Portage Avenue, Winnipeg, Manitoba R3G 0T3 at 204-945-8509. It is my responsibility to immediately notify Manitoba Student Aid, in writing, of any changes to personal, educational, financial, or alternate contact information that I have provided on this Application. If I fail to provide complete, accurate and updated information this may result in my being required to repay all of the financial assistance that I receive under the NPEG, and may preclude me from receiving any future financial assistance under the NPEG. If this Application is approved, I will sign a Contract with the Province of Manitoba in the form and content approved for this purpose by Manitoba Health and Manitoba Education and Advanced Learning. I hereby authorize: Manitoba Student Aid to receive information (including that related to education and employment) from and to provide information to educational institutions, financial institutions, consumer credit reporting agencies, employers, service providers, government agencies or authorities and any other persons considered necessary for the purposes of verifying or investigating this Application; administering and enforcing the contract and any laws pertaining to Manitoba Student Aid; and keeping and analyzing statistical records. Also, I understand that a condition of participating in the program is that I will be required to consent to Manitoba Health disclosing my name, mailing address, contact information, program, and year of graduation for recruitment purposes to prospective employers in the Province of Manitoba, including (but not limited to) regional health authorities, hospitals and clinics. I make this Declaration and Authorization knowing that: In return for any financial assistance received in the 2014/15 year, upon completion of my Nurse Practitioner training program, I will return to/remain in the Province of Manitoba and practice in the field for which I was trained, for a minimum period equal to twelve calendar months in a Nurse Practitioner position of 0.6 EFT or more. Should I fail to fulfill the full return-of-service, I will immediately repay the balance owing under the Contract, plus interest accrued from the day the financial assistance was provided to the financial institution referred to in Section 600 of this Application. Financial assistance under this program is taxable to the recipient in the year in which it is received. While there will be no deductions at source, a T4A will be issued and I am responsible for including the amount of the financial assistance in my income in the year in which it is received. If, for any reason, I do not complete my Nurse Practitioner training program, I will be required to immediately repay all of the financial assistance that I receive under the NPEG, plus interest accrued from the day it was provided to my financial institution. If I default in returning service, fail to repay any financial assistance received under the NPEG, or provide any inaccurate, false, or misleading information on this Application, notice of such default may be provided to Canada Revenue Agency, financial institutions, consumer credit reporting agencies, and/or collection agencies acting on behalf of the Government of Manitoba, and my credit rating will be affected. If I default on my NPEG debt repayments, Section 47 of The Financial Administration Act (right of Set-Off) may apply. I may be required to immediately repay all or part of the assistance I receive if my assessment is found to be inaccurate, even if such inaccuracy is a result of an inadvertent error on my part or on the part for the Manitoba Education and Advanced Learning. There is no obligation on the part for the Government of Manitoba to provide me with financial assistance under the NPEG. I have read and fully understand the contents of this Application. Signature Date page 6 of 7
SECTION 600 Financial Information In order to ensure proper Electronic Funds Transfer (EFT) of your Nurse Practitioner Education Grant, Manitoba Student Aid requires your banking information. Your application is not considered complete until this information has been received. Have your Financial Institution complete and stamp this form, attach a personalized void cheque, or provide a Direct Deposit form issued by your bank. Note: You must also sign the form at the bottom. First Name: Last Name: Financial Institution: Address of Financial Institution: City or Town: Province: Bank No.: Transit No.: Account No.: Bank Phone No.: I certify that the information above is complete and accurate. Signature of Borrower Date Bank Stamp FOR OFFICE USE ONLY NPEG Amount $10,000.00 Processed by: Date: page 7 of 7