U.S. DOD Form dod-ngb-36-4

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U.S. DOD Form dod-ngb-36-4

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AIR NATIONAL GUARD STIPEND PROGRAM FOR READY RESERVE HEALTH CARE PROFESSIONS (PHYSICIANS) WRITTEN AGREEMENT (Initial Each Entry) (The Proponent is ANG/MPPAR) A. ACKNOWLEDGMENT

I hereby apply for participation in the Stipend Program for physicians in the Ready Reserve of the Air National Guard of the United States (ANGUS). In support of this application, I acknowledge the following: 1. I meet the following eligibility criteria: a. I am a graduate of a medical school. b. I am eligible for appointment designation, or assignment as a medical officer in the ANG. c. If already commissioned I have been performing satisfactory service as a commissioned officer in the Ready Reserve of the ANG. d. I am enrolled, or have been accepted for enrollment, in a residency program for physicians in a medical speciality designated by the Assistant Secretary of Defense for Health Affairs as a specialty critically needed by the United States Air Force in wartime. e. I posses a current, valid, and unrestricted license to practice medicine, and such additional health professional privileges as are required to pursue professional training in the critical specialty for which assistance is being provided. f. I am not affiliating to qualify for a military technician or an AGR position where membership in a Reserve component is a condition of employment (this provision does not apply to temporary technician or full­ time active duty assignments of less than 180 days, or members performing duty for the purpose of interdiction and counter-drug activities for which funds have been provided under section 112 of title 32). 2. I understand that the Stipend Program shall apply to me, as follows: a. I shall receive the stipend rate in effect for participants in the Armed Forces Health Professional Schol­ arship Program under DoD 7000.14-R, if I have agreed to serve in the Selected Reserve for the period or the remainder of the period of the residency program in which I am enrolled. I understand that this rate is subject to annual adjustments on July 1, of each year, as determined by the Secretary of Defense. DoD 7000.14-R contains provisions for payment of this incentive. b. After completion of my residency training, I shall be required to perform satisfactorily in the Selected Reserve in accordance with ANG regulations. Satisfactory participation in the Selected Reserve shall require at least 12 days of active duty (AD) each year. c. I shall incur a Selected Reserve obligation of 2 years for each year or partial year for which stipend assistance is provided. Repayment of the obligation shall begin on completion of my residency training program and shall be in the ANG and in the medical AFSC of , (which has been determined to be a critically NGB FORM 36-4, 1 OCT 97, (EF) (ADOBE v 4.0)

PAGE 2 OF 3 short wartime specialty for which Stipend Program participation is approved), unless excused under "conve­ nience of Government" criteria. However, no part of the obligation may be satisfied while I am participating in the Selected Reserve Loan Repayment Program and I must be able to fulfill required service obligations before my mandatory removal date. d. I shall not be eligible for stipend payments before I have been appointed, designated or assigned as a medical officer for service in the ANG. e. If I fail to complete, for any reason, the residency training program for which stipend assistance is provided, or fail to complete an incurred obligation, I may be required to either: (1). Perform 1 year of active duty (AD) for each year (or part thereof) for which stipend assistance was provided; or (2). Repay the Government an amount equal to the amount paid to me under the Stipend Program. f. I shall be subject to such AD requirements as may be specified as a part of this agreement and to AD in time of war or national emergency as provided by law for members of the Ready Reserve. 3. I understand that my entitlement under this program continues unless or until I do one of the following: a. Transfer to an ineligible military specialty or ineligible health professions specialty, unless at the direction of the ANG. forces). b. Separate from the ANG for any reason (including appointment or voluntary order to AD in the active c. Accept a military technician or an AGR position where membership in the ANG is a condition of employment (this provision does not apply to temporary technician or full-time active duty assignments of less than 180 days, or members performing duty for the purpose of interdiction and counter-drug activities for which funds have been provided under section 112 of title 32). d. Fail to participate satisfactorily in required training with the ANG, in accordance with ANG regula­ tions, unless the failure to participate satisfactorily was due to reasons beyond my control (i.e., death, injury, illness, or other impairment). e. Fail to maintain a current or unrestricted valid medical license, as required, and such additional certifi­ cation and privileges as may be required to practice as a health professional in the critical specialty for which stipend participation is authorized. f. Complete the contracted period of training or receive medical certification and privileges required to practice as a health professional in the critical specialty for which the stipend is authorized. g. Am dropped from the Stipend Program for deficiency in specialty training or voluntarily stop training in the critical specialty designated for the Stipend Program. 4. I understand that my termination from the Stipend Program for any of the reasons stated in subsections a NGB FORM 36-4, 1 OCT 97, (EF) (ADOBE v 4.0)

PAGE 3 OF 3 through g above, shall not relieve me of any military obligation imposed by any other law or regulation. B. UNDERSTANDING I have read each of the statements in Section A above, and I understand that they are intended to constitute all promises, representations, and agreements concerning my stipend entitlement. I further understand that this writ- ten agreement is executed subject to availability of funds and review of eligibility. ANG/MPPA's determination of ineligibility or lack of funds will cause this contract to be null and void. Any other promise, representation, or commitment made to me in connection with my stipend entitlement is written below in my own handwriting or is hereby waived. (If none, write "NONE".)

C. AUTHENTICATION

Signature of ROM Typed Name and Grade of Chief, Military Personnel Flight Signature of Member Signature of Chief, Military Personnel Flight Date Date NGB FORM 36-4, 1 OCT 97, (EF) (ADOBE v 4.0)

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