YOUR NAME

Last

First

Middle

YOUR ADDRESS

Street address

City

State

ZIP

TELEPHONE

Home telephone

Work telephone

E-MAIL(S)

Home e-mail

Work e-mail

YOUR CURRENT STATUS (check one):

____Student (graduating___________)              ____Graduate (Year:______________)

YOUR EMPLOYER IN THE FIELD OF PUBLIC INTEREST LAW 

Employer's name

Employer's telephone number

Employer's street address

City

State

ZIP

THE WORK YOU EXPECT TO DO FOR YOUR EMPLOYER IN THE FIELD OF PUBLIC INTEREST LAW
In the space below, please describe briefly the nature of the work you expect to do for your employer in the field of public interest law:

YOUR QUALIFIED DEBT

Total qualified debt you will owe at beginning of grant year $

Amount of qualified debt you must repay during grant year $

YOUR OTHER DEBT AND HOUSEHOLD DEBT
If you or a member of your household will owe substantial debt, other than qualified debt, during the grant year, list below the nature of the debt and the amount that must be repaid during the grant year. Use a separate sheet of paper if necessary.

Nature of debt	Total amount	Amount that must be repaid during the grant year
1.	$	$
2.	$	$
3.	$	$

YOUR INCOME

Your expected gross income during grant year $

Your spouse's expected gross income during grant year $

HOUSEHOLD INCOME
If your household will have income other than your income and your spouse's income during the grant year, list the income below. Use a separate sheet of paper if necessary.

Nature of household income	Amount of household income
1.	$
2.	$

LOAN REPAYMENT ASSISTANCE FROM ANY OTHER SOURCES
If you are receiving loan repayment grants or any other sort of loan repayment assistance from your employer or any other sources, please indicate those below.

YOUR ASSETS AND HOUSEHOLD ASSETS
Check the space  below that most accurately reflects the total value of assets that you and members of your household will own during the grant year, including home equity, bank accounts, securities, etc.

_____Less than $5,000      _____$5,000 - $25,000      _____$25,000 - $50,000      _____More than $50,000

HOUSEHOLD DEPENDENTS
If you will be responsible during the grant year for the living expenses of persons in your household other than yourself, enter the number of such persons here: ______

YOUR LONG-TERM CAREER GOALS
In the space below, describe briefly the connection between your expected employment in the field of public interest law and your long-term career goals:

YOUR PRIOR COMMITMENT TO PUBLIC SERVICE
In the space below, describe briefly any activities that demonstrate your prior commitment to public service:

YOUR LAW SCHOOL CAREER
In the space below, describe briefly any features of your law school career that you believe should be considered in evaluating your application, including academic performance, courses taken, co-curricular activities, extracurricular activities, etc.

YOUR CAREER PLANS
Check the statement below that most accurately reflects your current career plans:

_____I intend to remain employed in the field of public interest law throughout my career.
_____I intend to remain employed in the field of public interest law for at least the next five years.
_____I intend to remain employed in the field of public interest law for at least the next two years.

YOUR SIGNATURE AND THE DATE
I swear or affirm that, to the best of my knowledge, the statements I have made in this application are true and that I have read and understand the Charter of the Loan Repayment Assistance Program of the University of Georgia School of Law and agree to abide by the terms of the Charter.

Your signature

The date