(1) Proof of licensure, including license number issued by the California Board of Behavioral Sciences or the California Board of Psychology, or proof of registration, including registration number issued by the California Board of Behavioral Sciences, or a unique identification number issued by the California Board of Psychology.

(2) Current employment as a licensed mental health service provider providing direct patient care in or through a qualified facility or in a mental health professional shortage area.

(3) The loan repayment amount requested with documentation on outstanding educational loans related to education required to become a licensed mental health service provider, including the current outstanding loan balance(s);

(4) Community background and involvement;

(5) Career goals;

(6) Cultural and linguistic competence;

(7) Two (2) letters of recommendation, dated within six (6) months of the application deadline, including author's name, mailing address, phone number, and relationship to applicant. Letters may comment on applicant's work experience, community service, volunteer activities, memberships in clubs, and/or attributes that indicate the applicant's likelihood to continue to practice in or through a qualified facility or in a mental health professional shortage area after service obligation has ended;

(8) A personal statement indicating qualifications, attributes, or characteristics that would increase the likelihood the applicant would continue to provide direct patient care in or through a qualified facility or in a mental health professional shortage area in California after service obligation has ended; and

(9) Any other information the applicant believes is relevant.