Form VS 1-5 VS 1-5 Nomination Request Form

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 0579-0353. The time required to complete this information collection is estimated to average .333 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.			OMB APPROVED 0579-0353 EXP DATE XX/XXXX
UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE VETERINARY SERVICES	NOMINATION REQUEST FORM
** This section to be completed by the Training Coordinator**	PRIORITIZED NUMBER:___________________________________________________________
COURSE TITLE:		DATE OF THE COURSE:
PARTICIPANT'S NAME (DR., MR., MS., MRS.):
MAILING ADDRESS (Street, City, State, ZIP Code, and Country):
WORK PHONE NUMBER:		WORK FAX NUMBER:
(Government or Business) CELL PHONE NUMBER:		WORK EMAIL ADDRESS:
CHECK ONE: FEDERAL EMPLOYEE STATE EMPLOYEE OTHER
AGENCY/ORGANIZATION:
JOB TITLE:
PARTICIPANT'S OFFICIAL DUTY STATION:
SUPERVISOR'S APPROVAL:
REGION'S APPROVAL:

PLEASE FAX THE COMPLETED NOMINATION FORM TO YOUR TRAINING COORDINATOR. THE TRAINING COORDINATOR WILL FAX TO THE PROFESSIONAL DEVELOPMENT STAFF.

A LIST OF TRAINING COORDINATORS CAN BE FOUND IN THE VETERINARY SERVICES TRAINING CATALOG ON THE WEB AT:

HTTP:/WWW.APHIS.USDA.GOV/ANIMAL_HEALTH/PROF_DEVELOPMENT/

VS FORM 1 - 5

JAN 2012