Sign-up to Become an LRP Ambassador

I am willing to serve as an LRP Ambassador.

I understand that my responsibilities as an LRP Ambassador are to:

Learn about the LRPs and the application process in order to be an informed communicator.
Identify potential eligible applicants to the LRPs within their institutions.
Share relevant information about the LRPs to these potential applicants in a timely manner through face-to-face encounters, electronic communication, and planned events.
Share/report information on their activities with NIH/DLR staff.

Full Name

Institution

Position/Title

Degree(s)

Year(s) Received LRP

This should be a range/list of ranges of the years in which you received your LRP (xxxx-xxxx)

Type of LRP

Primary Research Interest

Short format only: name@example.com

Telephone

Phone format: 123-456-7890

Address

City

State

ZIP

Permission to use personal information*

I do hereby grant or deny permission to the National Institutes of Health (NIH) Loan Repayment Programs (LRP) to use my name, contact details, biography, professional details and image as indicated below. Such use includes the display, distribution, publication, transmission, or otherwise use of this information in materials that include, but may not be limited to, the NIH LRP website, as well as printed materials such as brochures and newsletters, videos and digital images.

Choose one of the following:

Grant permission to share my name and contact information on the LRP website and share my biography, professional details and image as a part of the LRP awardee “success stories” highlights featured on the LRP website.

Grant permission to publish my name, institution, telephone number, and email address on the LRP website as part of a directory of LRP Ambassadors.

Grant permission to the NIH LRP to share my name and contact information only upon the request of individuals at my current or nearby Institutions seeking information about the NIH LRPs.

I understand that NIH LRP staff will contact me for my approval/permission prior to providing my contact information.

Deny permission to NIH’s LRP to share my personal information in any way.

Check here to indicate that you have read and agree to the terms of the Sign-up Form for Ambassadors.

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0648). Do not return the completed form to this address.

I am willing to serve as an LRP Ambassador.

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*Quarterly Payment Breakdown*
Year 1	Year 2	Year 3
Quarter 1	Quarter 5	Quarter 9
Quarter 2	Quarter 6	Quarter 10
Quarter 3	Quarter 7	Quarter 11
Quarter 4	Quarter 8	Quarter 12