National Veterinary Accreditation Program

Applicant instructions for completing VS form 1-36A, National Veterinary Accreditation Program Application Form, This form must be completed, signed, and dated by the
applicant before submission. Original signature is required. (NOTE: The applicant MUST be licensed or legally able to practice as a veterinarian.)
(Please check all appropriate Blocks for which you are applying):
Block 1. Initial Accreditation: Check this Block if this is your first time applying for
accreditation. Enter the 2 letter State abbreviation for which you are seeking
authorization to perform accredited duties on the application State line and your
complete veterinary license number for this specific State. (Note: If you do not have a
license number, but are legally able to practice please enter LAP in the veterinary
license number field)

Block 23. ZIP Code: Enter the 5 or 9 digit ZIP code of your home address—whichever
is applicable.

Block 2. Authorization in a new State: Check this Block if you are already accredited
and are seeking authorization to perform accredited duties in an additional State. Enter
the 2 letter abbreviation for the State which you are seeking authorization to perform
accredited duties and your complete veterinary license number for this specific State.
(Note: If you do not have a license number, but are legally able to practice please enter
LAP in the veterinary license number field)

Business Contact Information
Block 25. Name of Business: Enter the name of the business where you
work/practice. If you are self employed without a specific business name, enter your
own name.

Block 3. Choose Accreditation Category: Check this Block if you are choosing an
Accreditation Category for the first time or changing your category.
Block 4. Contact Information Change: Check this Block if you are changing your
contact information (home or business). Complete the appropriate CONTACT
INFORMATION fields.

Block 24. If your home contact information is the same as your business contact
information, may it be released to the public? Enter either “yes” or “no” if you want
your home/business contact information available through an APHIS Web site for the
public to use when trying to locate an accredited veterinarian.

Block 26. County of Business Mailing Address: Enter the name of the county in
which business address is located.
Block 27. Business Mailing Address: Enter complete business mailing address. If
your home mailing address is your business mailing address, write “Same as home
address.”
Block 28. Business Telephone: Enter 10-digit business telephone number
(xxx-xxx-xxxx)

Block 5. Accreditation Renewal: Check this Block if you are renewing your
accreditation. Renewal is required every 3 years in order to retain your authorization to
perform accredited duties.

Block 29. Business FAX: Enter 10 digit fax number (xxx-xxx-xxxx). This number will
be the used by NVAP to communicate with you via FAX.

Block 6. Post -Revocation Reaccreditation: Check this Block if your accreditation
was revoked and you are applying for reaccreditation.

Block 30. Business Cell Number (optional): Enter your 10-digit cell phone number
of your business (xxx-xxx-xxxx).

Block 7. Name of Veterinarian: Enter your last name, first name and middle initial (If
this is a name change request, enter your legal name in this Block.) Check the Block, if
your name has changed.

Block 31. City: Enter city of your business address.

Block 8. Six Digit National Accreditation No.: Enter the national accreditation
number that you have been assigned. (If this is your initial accreditation or first time
choosing an Accreditation Category, you will not have a number and you may leave this
Block blank) Upon your initial accreditation (for first time applicants) or initial
Accreditation Category selection (currently accredited veterinarians), you will be notified
via mail +/- email of your National Accreditation No.

Block 33. ZIP Code: Enter the 5 or 9 digit ZIP code of your business address —
whichever is applicable.

Block 9. Other Names Used (e.g., Maiden Name): Enter other names used – for
example, maiden name, nickname (this name should not be the same name as in
Block 7).

Block 32. State: Enter state of your business address.

Block 34. May your business contact information be released to the public?
Enter either “yes” or “no” if you want your business contact information available
through an APHIS Web site for the public to use when trying to locate an accredited
veterinarian.

Block 11. School of Veterinary Medicine: Enter the name of the school of veterinary
medicine from which you graduated. Do not use the 3-letter school code abbreviation.

Professional Information
Block 35. State Veterinary License Number: Enter the 2 letter State abbreviation(s)
for all States in which you are authorized to perform accredited duties on the
application State line and the complete license number for each specific State,
respectively. If this is your initial accreditation, leave blank. (Note: If you are not
licensed, but are legally able to practice (LAP) please enter “LAP” in the veterinary
license number field, and submit written authorization from the State licensing board(s)
for each state in which you are legally able to practice without a license.)

Block 12. Year Graduated: Enter your four-digit year of graduation from a school of
veterinary medicine (yyyy).

Block 36. Species Category (may list up to 2): Using the list provided, determine
your Species Category or up to 2 Species Categories from the species code(s).

Block 13. State where Orientation Completed: Enter the State where core
orientation was completed.

Block 37. Species Code(s): Using the list provided, enter the code(s) associated with
all the species with which you expect to perform accredited duties

Block 14. Are you interested in participating in State or Federal agricultural
emergency response efforts? Check yes, if you would like to be contacted if there is
an agricultural emergency event for which accredited veterinarians are being sought, or
no if you don’t want to be contacted.

Block 38. Primary Medical Discipline: Using the list provided, enter the one or two
digit number associated with discipline that best describes your primary medical
discipline.

Block 10. Date of Birth: Enter the 2 digit month, 2 digit day, and 4 digit year of your
birth (mm/dd/yyyy).

Category Selection
Block 15. Category I: Check this Block if performing accreditation duties on Category
I animals: any animals other than Category II animals, e.g., laboratory rodents, cats
and dogs. This category requires completion of 3 units of training by renewal date.
Block 16. Category II: Check this Block if performing accreditation duties on
Category II animals such as: Food and fiber animal species; horses; birds; farm-raised
aquatic animals; all other livestock species; and zoo animals that can transmit exotic
animal diseases to livestock. Category II veterinarians may also perform accredited
duties on Category I animals. This category requires completion of 6 units of training
by renewal date.
Home Contact Information
Block 17. Home Mailing Address: Enter your complete home mailing address. This
is the address that will be used by NVAP to communicate with you about the National
Veterinary Accreditation Program (NVAP) through the U.S. Postal Service.
Block 18. County of Home Mailing Address: Enter the county in which your home
address is located
Block 19. Home Telephone: Enter 10-digit home telephone number (xxx-xxx-xxxx).
Block 20. Email Address: Enter email address. This address will be used by NVAP
to communicate with you via e-mail. (NOTE: If you enter a shared email address, note
that information may be viewable to others.)
Block 21. City: Enter city of your home address.
Block 22. State: Enter State of your home address.

VS 1-36A
SEP 2009

Block 39. Employment Type: Using the list provided, enter the one or two digit
number associated with your employment type
Accreditation Renewal
Block 40. Course Title: Enter the title of the APHIS approved course you completed.
Block 41. Organization Administering the Course: For example: university name,
state agriculture department name, etc.
Block 42. Course Type: Enter manner in which the course was administered (e.g.,
online, hard-copy text, etc).
Block 43. Units: Enter the number of units completed.
Block 44. Date Completed: Enter 2 digit month, 2 digit day, and 4 digit year that you
completed the course/unit (mm/dd/yyyy).
Certification/Approval
Block 45. Signature of Veterinarian: Sign in black or blue ink. Signature on this form
certifies that you can perform the tasks for accredited veterinarians listed in
9 CFR Part 161 and have received a copy of the Standards for Accredited Veterinarian
Duties, and agree to conduct all accredited veterinarian activities in accordance with
those “standards”. If you are signing for accreditation Renewal this certifies that you
completed the courses listed on the application.
Block 46. Date: Enter the complete date (mm/dd/yyyy) of when you signed in
Block 45.
Blocks 47-50: Do not enter any information in these blocks.

PRIVACY ACT NOTICE
General:
This information is provided pursuant to Public Law 95-3579 (Privacy Act of 1974) December 31, 1974, for individuals completing the VS 1-36A.
Authority:
5 U.S.C. 3301, 7 U.S.C. 8309, and 21 U.S.C. 113a
Routine Uses:
The information will be used for (1) Referral to State Animal Health officials to certify accreditation status or to exchange information regarding disciplinary action(s). (2)
Referral to state veterinary examining boards to certify accreditation status or to exchange information regarding disciplinary action(s). (3) Disclosure to the public for the
purpose of locating and contacting accredited veterinarians for a specific geographical location. (4) Referral to the appropriate agency, whether Federal, State, local or
foreign, charged with the responsibility of investigating or prosecuting a violation of law, or of enforcing or implementing a statute, rule, regulation or order issued pursuant
there to, of any record within this system when information available indicates a violation or potential violation of law, whether civil, criminal or regulatory in nature, and
whatever arising by general statue or particular program statue, or by rule, regulation or order issued pursuant thereto. (5) Disclosure to the Department of Justice has
agreed to represent the employee or the United States, where the agency determined that litigation is likely to affect the agency or any of its components, is a party to litigation
or has an interest in such litigation and the use of such records by the Department of Justice is deemed by the agency to be relevant and necessary to the litigation ; provided,
however, that in each case the agency determines that disclosure of the records to be Department of Justice is a use of the information contained in the records that is
compatible with the purpose for which the records were collected. (6) Disclosure in a proceeding before a court of adjudicative body before which the agency is authorized to
appear, when the agency, or any component thereof, or any employee of the agency in his or her official capacity, or any employee of the agency in his or her individual
capacity where the agency has agreed to represent the employee or the United States, where the agency determines that litigation is likely to affect the agency or any of its
components, is a party to litigation or has an interest in such litigation, and the agency determines that use of such records is relevant and necessary to the litigation; provided,
however, that in each case the agency determines that disclosure of the records to the court is a use of the information contained in the records that is compatible with the
purpose for which the records were collected (7) Disclosure to appropriate agencies, entities, and persons when the agency suspects or has confirmed that the security or
confidentiality of information in the system of records has been compromised; the agency has determined that as a result of the suspected or confirmed compromise there is a
risk of harm to economic or property interests, a risk of identity theft or fraud, or a risk of harm to the security or integrity of this system or other systems or programs (whether
maintained by the agency or another agency or entity) that rely upon the compromised information; and the disclosure made to such agencies, entities, and persons is
reasonably necessary to assist in connection with the agency’s efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm; (8)
Disclosure to cooperative Federal, State, and local government officials, employees, or contractors, and other parties engaged to assist in administering the program. Such
contractors and other parties will be bound by the nondisclosure provisions of the Privacy Act. This routine use assists the agency in carrying out the program, and thus is
compatible with the purpose for which the records are created and maintained. (9) Disclosure to USDA contractors, partner agency employees or contractors, or private
industry employed to identify patterns, trends or anomalies indicative of fraud, waste, or abuse. (10) Disclosure to the National Archives and Records Administration or to the
General Services Administration for records management inspections conducted under 44 U.S.C. 2904 and 2906.
Effects of Nondisclosure:
Although this information is voluntary, failure to complete all the information may delay the process of the application or it may result in the application not being processed.

VS 1-36A
SEP 2009

Explanation of Codes and Key Numbers
ID – SPECIES CATEGORY (Block 36)
(May indicate up to 2 categories)
1 - Food Animal Predominant – sum of
Species Codes (4, 5, 6, 7, 8, 9) is at
least 50% of contact
2 - Food Animal Exclusive – sum of
Species Codes (4, 5, 6, 7, 8, 9) is at
least 90% of contact
3 - Companion Animal Predominant –
sum of Species Codes (1, 2, 10, 11) is
at least 50% of contact
4 - Companion Animal Exclusive – sum of
Species Codes (1, 2, 10, 11) is at least
90% of contact
5 - Mixed Animal – varied species with at
least 25% from companion animal and
25% from either food animal and
equine
6 - Equine Predominant – Species Code
(3-Equine) is at least 50% contact
7 - Equine Exclusive – Species Code
(3-Equine) is at least 90% contact
8 - Other
9 - No Species Contact
SPECIES CODES (Block 37)
1 - Canine
2 - Feline
3 - Equine
4 - Bovine
5 - Porcine
6 - Ovine/Caprice
7 - Camelid
8 - Cervid
9 - Poultry
10 - Avian (non-poultry)
11 - Exotics
12 - Amphibian/Reptile
13 - Aquatic Animal
14 - Zoo Animal
15 - Wildlife
16 - Furbearing Animals
17 - Laboratory Animal
18 - Non Human Primate
19 - Other Species
ID – PRIMARY MEDICAL DISCIPLINE
(Block 38)
1 - Anatomy
2 - Anesthesiology
3 - Animal Behavior
4 - Animal Welfare

5678910 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 -

Alternative/Contemporary
Association Management
Biochemistry
Biomedical Engineering
Business/Economics
Cardiology
Dentistry
Dermatology
Disaster Medicine
Ecology
Emergency and Critical Care
Endocrinology
Environmental Health
Epidemiology
Ethics
General Medicine
Genetics
Human Animals Bond
Homeland Security
Immunology
Internal Medicine
Insurance
Laboratory Animal Medicine
Law
Media
Microbiology
Mycology/Bacteriology
Molecular Biology
Neurology
Non-Medical
Nutrition
Oncology
Ophthalmology
Parasitology
Pathology - Anatomic
Pathology – Clinical
Pharmacology
Pharmacology – Clinical
Physiology
Population Medicine
Poultry Medicine
Preventative Medicine
Production Medicine
Public Health
Radiology
Shelter Medicine
Sports Medicine
Surgery
Theriogenology
Toxicology
Virology
Wildlife Medicine

"This Professional Classification System is used courtesy of the American Veterinary Medical Association."

VS 1-36A
SEP 2009

57 - Zoological Medicine
58 - Other Professional Discipline
ID – EMPLOYMENT TYPE (Block 39)
(Member may choose up to 2)
Private Clinical Practice
1 - General Medicine/Surgery
2 - Production Medicine
3 - Referral/Specialty Medicine
4 - Emergency/Critical Care Medicine
5 - Other Private Clinical Practice
Academia
6 - Veterinary Medical College/School
7 - Veterinary Science Department
8 - Veterinary Technician Program
9 - Animal Science Department
10 - Other Academia
Government
11 - U.S. Federal
12 - State
13 - Local
14 - Foreign
15 - Army
16 - Air Force
17 - Public Health Commission Corps
18 - Other Government
Industry/Commercial
19 - Pharmaceutical/Biological
20 - Feeds/Nutrition
21 - Laboratory
22 - Agriculture/Livestock Production
23 - Business/Consulting Services
24 - Other Industry/Commercial
Other
25 - Humane Organization
26 - Membership Assn/Professional
Society
27 - Foundation/Charitable Organization
28 - Missionary/Service
29 - Zoo/Aquarium
30 - Wildlife
32 - Temp Not Employment in Veterinary
Field
33 - Non-Veterinary Employment
34 - Not Employed
35 - Not Listed Above