(A) An individual who has not received other student loan repayment assistance and meets either of the following requirements may apply for participation in the chiropractic loan repayment program:

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(1) The individual is a chiropractic student enrolled in the final year of chiropractic school or college.

(2) The individual holds a current, valid license to practice chiropractic issued under Chapter 4734 of the Revised Code.

(B) An application for participation in the chiropractic loan repayment program shall be submitted to the director of health on a form that the director shall prescribe. The information required to be submitted with an application includes the following:

(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 chiropractic school or college the applicant is attending or attended, the dates of attendance, and verification of attendance;

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

(4) If applicable, verification of the applicant’s current, valid license to practice chiropractic issued by the state chiropractic board under Chapter 4734 of the Revised Code;

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