Martha Mordini Rukavina Application 2017-18 · Dr. Bashar Bakdash ... • Official transcripts from all dental and graduate schools attended. ... Martha Mordini Rukavina Application

MarthaMordiniRukavina

LoanForgivenessProgram

InformationandApplication2018

Formoreinformationcontact:Dr.BasharBakdash

[email protected]

TheapplicationprocesswillopenJanuary17,2018andremainopenaslongasthereareadequateuncommittedfunds.

Sendtotheapplicationandothermaterialsto:MinnesotaDentalFoundation1335IndustrialBlvd.,Suite200

Minneapolis,MN55413Fax:612-767-8500

Email:[email protected]

PURPOSETheMarthaMordiniRukavinaLoanForgivenessProgramisacompetitiveprogramtoprovideanincentivetoattractdentiststopracticegeneraldentistryfull-timeintheTaconiteAssistanceArea(TAA)ofnortheasternMinnesota.TheTAAisanareathathasadocumentedneedfordentistswhowillprovideservicestoitscommunitiesandunderservedpopulations.(Seeattachedmap.)Whiletherearenospecificrequirementsastothenumbersorpercentagesofpubliccarepatientsoruninsuredpatientsthatneedtobeseen,itisexpectedthatrecipientsofMarthaMordiniRukavinaLoanForgivenessProgramfundswillseeasignificantnumberofthesepatients.APPLICANTELIGIBILITY•ApplicantmustbeaUSCitizenorUSPermanentResident(GreenCardholder).•ApplicantmustholdaDDSorDMDorequivalentdegreeorplanonreceivingonewithin6monthsoftheapplication.

•ApplicantmustholdalicensetopracticedentistryintheStateofMinnesotaorplanonreceivingonewithin6monthsoftheapplication.

•ApplicantmusthavedocumentededucationaldebtheldbytheUSDepartmentofEducationoracommerciallender.(Loansfromfamilymembersorothernon-institutionalsourcesarenoteligibleforloanrepaymentassistance.)

•ApplicantmustnotbeinpracticeintheTAAatthetimeofapplication.•Applicantmustcommittopracticefull-time(atleastfourdaysperweek)intheTAAforfiveyearsfromthedateofreceiptofthefirstinstallmentoftheforgivableloan.

FUNDINGItistheintentofthisprogramtomakeloanforgivenessfundsavailabletoadentistwhocommitstopracticinggeneraldentistryfull-timeintheTAA.Forgivableloanamountsofupto$120,000,nottoexceedtheapplicant’sdocumentedoutstandingeducationaldebt,willbedispersedatarateof$30,000peryearforfouryears,commencing90daysafterthefirstpatientisseen.Failureoftherecipienttomaintainafull-timegeneralpracticeinthedentalshortageareaoftheTAAforaperiodoffiveyearswillresultina100%forfeitureofallmoniesreceivedaswellasaccruedinterest.Allrecoveredfundswillbeawardedtoanotherindividualusingthesameselectioncriteria.Applicanthas90daysfromtheletterofacceptanceortheawardingofalicensetopracticedentistryinMinnesotatonotifytheMinnesotaDentalFoundationoftheirintentiontoaccepttheforgivableloan.EVALUATIONANDCRITERIAEachapplicantwillbeevaluatedforselectionbaseduponinformationprovidedontheapplicationandduringthepersonalinterview.Thecriteriawillinclude,butisnotlimitedtowhereandhowtheapplicantintendstopractice,educationalhistory,grades,writtenstatementandpreviousexperience.TheMinnesotaDentalFoundation,alongwithitsselectionconsultants,reservestherighttodeterminetheweighingofanycriteria.Allapplicationswillbereviewedandforgivableloansawardedwithoutreferencetorace,gender,disabilityoranyotherprotectedclassstatus.Onceinpractice,itisexpectedthattherecipientwillparticipateinatleastoneprogramoftheMinnesotaDentalFoundationsuchasGiveKidsaSmile,MissionofMercyorDonatedDentalServices.Also,itisanticipatedthattherecipientwillmaintainmembershipintheMinnesotaDentalAssociation,theAmericanDentalAssociationandacomponentdistrictdentalsociety.APPLICATIONPROCESSPleasesubmitthecompletedapplicationtotheMinnesotaDentalFoundation.Applicationswillremainopenaslongasthereareavailablefunds.ApplicationsandinformationareavailableontheMinnesotaDentalFoundation’swebsite,mndentalfoundation.org.Allapplicationsareevaluatedonanindividual

basis.Apersonalinterviewmaybeconductedafterreviewofyourwrittenapplication.Theapplicationshouldinclude:•Acompleted,legibleprogramapplicationform.•Officialtranscriptsfromalldentalandgraduateschoolsattended.•Resume´outliningeducation,workandvolunteerexperiences.•Documentationofoutstandingstudentloandebtandanyotherloanrepaymentassistance.•AwrittenstatementofnomorethanthreepagesstatingwhytheapplicantwishestopracticeintheTAAandwhattheapplicant’sspecificcareerplansarefortheirpracticeintheTaconiteAssistanceArea.

•Abusinessplan,ifapplicable,totheTAApractice.•Aleastoneletterofrecommendationbutnomorethanthreeletters.•Anyotherletters,exhibits,ordocumentsthatsupporttheapplication.Theapplicationcanbemailed,faxedoremailedtotheMinnesotaDentalFoundationtotheaddressorfaxoremailaddressonthecoverofthisapplication.Receiptoftheapplicationwillbesenttotheapplicant.

MarthaMordiniRukavinaLoanForgivenessProgramApplicationFirstName______________________________MI___Last__________________________________

Address______________________________________________________________________________

City___________________________________________________State____Zip_________________

Telephone(_____)___________CellPhone(_____)__________Email___________________________

DateofBirth___________________PlaceofBirth___________________________________________

SocialSecurityNumber__________________________________________________________________

EducationalInformation

UndergraduateSchool___________________________________________________________________

DatesAttended______________________________________Degree___________________________





DentalSchool___________________________________________GraduationDate_______________


GraduateSchool_________________________________________GraduationDate_______________


FinancialInformation

EducationCost:Undergraduate____________________Graduate/Dental________________________

EducationDebt:Undergraduate____________________Graduate/Dental_______________________

ProfessionalPlans

PracticeLocationCity_____________________________________________BusinessPlanAttached!

EstimatedStartDate______________StartingNewPractice! Purchasing/JoiningExistingPractice!

PersonalStatementAttached! DoyoucurrentlyhaveaMinnesotaDentalLicense?Yes! No!

Ideclareunderpenaltyofperjurythattheinformationonthisapplicationistrueandcompletetothebestofmyknowledge.IfaskedbytheMinnesotaDentalFoundation,Iagreetoprovideadditionalverificationasrequested.TheMinnesotaDentalFoundationdoesnotprovideadviceonthetaximplicationsofthisloan.Applicant’sSignature_______________________________________________Date_______________

Documents

Martha Mordini Rukavina Application 2017-18 · Dr. Bashar Bakdash ... • Official transcripts from all dental and graduate schools attended. ... Martha Mordini Rukavina Application