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

1. (1) The applicant is a dental hygiene student enrolled in the final year of dental hygiene school.
2. (2) The applicant holds a valid license to practice dental hygiene issued under Chapter 4715. of the Revised Code.

(B) An application for participation in the dental hygienist 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. (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 dental hygiene school the applicant attended or is attending, dates of attendance, and verification of attendance;
3. (3) A summary and verification of the educational expenses for which the applicant seeks reimbursement under the program;
4. (4) If the applicant is a licensed dental hygienist, verification of the applicant's license issued under Chapter 4715. of the Revised Code to practice dental hygiene and proof of good standing;
5. (5) Verification of the applicant's United States citizenship or status as a legal alien.