Form VS-1-36A National Veterinary Accrediation Program Application For

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0579-XXXX. The time required to complete this collection of information is estimated to average .5 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
NATIONAL VETERINARY ACCREDITATION PROGRAM

APPLICATION FORM
7. Name of Veterinarian (Last, First, M, Suffix):

9. Other Names Used (e.g., Maiden Name):
13. State where Orientation Completed:

15.

OMB Approved
0579-XXXX
Exp. XX/XXXX

1.

Initial Accreditation
State:
Lic No:

2.

Authorization in a new State
State:
Lic No:

3.

Choose Accreditation Category (Block 15 or 16)

4.

Contact Information Change

6

Post-Revocation Re-accreditation

5.

Accreditation Renewal

Check if your name has changed.

10. Date of Birth:

8. Six Digit National Accreditation No:

11. School of Veterinary Medicine:

12. Year Graduated:

14. Are you interested in participating in State or Federal agricultural emergency response efforts?

Yes

No

ACCREDITATION CATEGORY SELECTION (select only one)
Category I animals, as defined in 9 CFR Part 160.1
16.
Category II animals, as defined in 9 CFR Part 160.1
requires 3 units of APHIS approved courses for renewal)
requires 6 units of APHIS approved courses for renewal)
HOME CONTACT INFORMATION
18. County of Home Mailing Address:

17. Home Mailing Address:

19. Home Telephone:
20. Email Address:
21. City:

22. State:

23. ZIP Code:

24. If your home contact information is the same as your business contact information, may it be
released to the public by USDA?
Yes
No

PRIMARY BUSINESS CONTACT INFORMATION
26. County of Business Mailing Address:

25. Name of Business:
27. Business Mailing Address:

28. Business Telephone:
29. Business Fax:
30. Business Cell Telephone:

31. City:

32. State:

33. ZIP Code:

34. May your business contact information be released to the public by USDA?
Yes
No

35. LIST ALL STATE(S) AND VETERINARY LICENSE NUMBER(S) WHERE YOU ARE CURRENTLY AUTHORIZED TO PERFORM ACCREDITED DUTIES
State:

Lic No:

State:

Lic No:

State:

Lic No:

State:

Lic No:

State:

Lic No:

State:

Lic No:

State:
Lic No:
36. Species Category:

State:
37. Species Code(s):

Lic No:

State:
38. Primary Medical Discipline:

Lic No:
39. Employment Type:

ACCREDITATION RENEWAL – Complete only if Accreditation Renewal Block 5 is checked
40. Course Title (Must be APHIS approved)

41. Organization Administering Course

42. Course Type

43. Units

44. Date Completed

I certify that I am able to perform the tasks listed in 9 CFR Part 161.1(g) for the appropriate Accreditation category in Blocks 16 or 17 and have been given a copy of the Standards of Accredited
Veterinarian Duties. I agree to conduct all activities as an Accredited Veterinarian in accordance with the Standards of Accredited Veterinarian Duties contained in Title 9, Code of Federal Regulations.
Subchapter 3, Part 161.4 and any amendments there to which may subsequently be issued and in accordance with instructions received from the APHIS representative. I certify that I have completed all
courses listed in Block 40.
45. Signature of Veterinarian:
46. Date:

Signature of the Veterinarian-in-Charge and the State Animal Health Official appearing below denotes endorsement of the applicant for veterinary accreditation and/or authorization in a new State.
Signatures are NOT required for Accreditation Renewal or Change in Accreditation Category.
47. Signature of State Animal Health Official:
48. Date:

49. Signature of Veterinarian-in-Charge:

VS 1-36A
SEP 2009

50. Date: