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

1. (1) The primary care physician is enrolled in the final year of an accredited program required for board certification in a primary care specialty.
2. (2) The primary care physician is enrolled in the final year of a fellowship program in a primary care specialty.
3. (3) The primary care physician holds a valid license to practice medicine and surgery or osteopathic medicine and surgery issued under Chapter 4731. of the Revised Code.

(B) An application for participation in the physician 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. (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. (2) The applicant's primary care specialty or specialties;
3. (3) The medical school or osteopathic medical school the applicant attended, the dates of attendance, and verification of attendance;
4. (4) The facility or institution where the applicant's medical residency program was completed or is being performed, and, if completed, the date of completion;
5. (5) If applicable, the facility or institution where the applicant's fellowship was completed or is being performed, and, if completed, the date of completion;
6. (6) A summary and verification of the educational expenses for which the applicant seeks reimbursement under the program;
7. (7) Verification of the applicant's authorization under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery;
8. (8) Verification of the applicant's United States citizenship or status as a legal alien.