(A) An individual who will not have an outstanding obligation for dental service to the federal government, a state, or other entity at the time of participation in the dentist loan repayment program and meets one of the following requirements may apply for participation in the dentist loan repayment program:

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(1) The applicant is a dental student enrolled in the final year of dental college.

(2) The applicant is a dental resident in the final year of residency.

(3) The applicant holds a valid license to practice dentistry issued under Chapter 4715. of the Revised Code.

(B) An application for participation in the dentist loan repayment program shall be submitted to the director of health on a form the director shall prescribe. The following information shall be included or supplied:

(1) The applicant’s name, permanent address or address at which the applicant is currently residing if different from the permanent address, and telephone number;

(2) The dental college the applicant attended or is attending, dates of attendance, and verification of attendance;

(3) If the applicant has completed a dental residency program or is a dental resident, the facility or institution where the dental residency was completed or is being performed, and, if completed, the date of completion;

(4) A summary and verification of the educational expenses for which the applicant seeks reimbursement under the program;

(5) If the applicant is a dentist, verification of the applicant’s license issued under Chapter 4715 of the Revised Code to practice dentistry and proof of good standing;

(6) Verification of the applicant’s United States citizenship or status as a legal alien.