Government of Ontario: Ministry of Health and Long-Term Care

Application for Tuition Support Program for Nurses

Please return this form to:
Primary Health Care Team
Underserviced Area Program

159 Cedar Street Suite 402
Sudbury ON P3E 6A5
Telephone: 705 564–7280
Fax: 705 564–7493

Funds provided through the Tuition Support Program for Nurses are subject to federal and provincial income tax.

Personal information contained on this document is collected by virtue of it being necessary for the proper administration of a lawfully authorised activity pursuant to Section 8 of the Ministry of Health and Long-Term Care Act, RSO 1990, Chapter M. 26. and, more specifically, for the purpose of establishing eligibility for the Tuition Support Program for Nurses. For information about this collection, please contact Manager, Underserviced Area Program, at 159 Cedar Street, Suite 402, Sudbury ON P3E 6A5, telephone no. 1 866–727–9959.

Please complete all sections

Surname
Given name
Present address
City
Postal Code

Telephone no.

E-mail address

I prefer to communicate in English French

What is your immigration status in Canada?

Canadian Citizen Landed Immigrant Other (specify)

College of Nurses of Ontario (CNO) Registration Number
Date of Registration

What type of program have you graduated from?

RPN RN BScN RC (EC)

Name of college / University attended
Graduation Date (month/year)

Is your current permanent residence located no more than 100 kms from the
underserviced community in which you wish to return service?

Yes No

Did you attend high school, for at least one full year, no more than 100 kms from
the underserviced community in which you wish to return service?

Yes No

Total tuition fee for which reimbursement is requested* $
* Tuition does not include books, student fees

Number of years for which reimbursement is requested**
** You will be required to provide 1 year of return of
service for each year of tuition reimbursed. You may
apply for all or part of your nursing education.

Have you received tuition or financial support in the form of grants from
any other source for this education program? Nursing Education Initiative (specify amount)
Other (specify source and amount)

I have attached proof of tuition paid (letter from school) for each academic year assistance is applied for
attached a copy of CNO Certificate of Registration
attached copies of Nursing Diplomas
attached an imprinted blank voided cheque for the bank account to which the funds will be deposited
Return of Service Agreement
Confirmation of Employment
Acceptance of Ministry Offer and Consent to Collection and Disclosure of Personal Information

I hereby certify that the information is true and correct.
I agree to participate in an evaluation of the program if needed.

Signature
Date