Exhibit A

Work Pledge Certification

Date: ______________

I, _______________________________________ (print name), hereby certify to San Joaquin Valley Medical Scholarship Foundation (“SJVMSF”), pursuant to the requirements of the Scholarship Agreement dated _______________ between SJVMSF and me (the “Agreement”), that I have worked as a physician serving primarily residents of the County of __________________ at

Name of Facility/Practice:

Physical Address:

continuously, on a full-time basis working at least 36 hours a week, during the period beginning ____________________, 20___ and ending December 31, 20___, except with respect to a Permitted Interruption from ____________ to ____________ [insert dates, if applicable], caused by _____________________________ [describe reason]. My practice is located in an Underserved Area and as shown in the attachment to this certification, at least 30% of the patients I accepted and treated were enrolled in Medi-Cal or were uninsured.

I hereby declare, under penalties of perjury, that my statements above are true, correct, and complete as of the date set forth above.

Signed: _____________________________