Form NIFA -01-10 NIFA -01-10 Loan Application Information

Name:

	NIFA Veterinary Medicine Loan Repayment Program (VMLRP)	National Institute of Food and Agriculture US Department of Agriculture NIFA-01-10 OMB No. 0524-0047
Applicant Information
Section 1. Identifying Information

The Loan Repayment Program is a competitive process and the submission of an application does not assure the award of benefits. Only designated agents of the U.S. Department of Agriculture (USDA) or acting on behalf of USDA can make commitments for VMLRP awards.

Application Type:

 NEW (individuals who have never had a VMLRP award)  RENEWAL (individuals who have had a VMLRP award)

Applicant’s Name:

First

Middle

Last

Suffix

Other Names Used: (e.g. maiden name)

Check the VMLRP website for the code of the shortage area to which you are applying. The code entered on this form MUST match the code entered on the Intent of Employment form (NIFA-07-10).

Please enter the five-character Shortage Identification Code:

Shortage Type (Mark one box):

  

Type I: Private Practice (minimum 80% time) Type II: Private Practice – Rural Area (minimum 30% time) Type III: Public Practice (minimum 49% time)

Important: An applicant may apply to fill only ONE shortage situation. Applications that list more than one shortage situation will be discarded.

Section 2. Residential Contact Information

Residential

Address:

City

State

Zip Code+4

Telephone Number:

-

-

(Area code required)

Fax Number: (optional)

-

-

(Area code required)

Email Address:

Section 3. Current Employment Contact Information

Position Title:		Organization/Practice:
Division/School:		Department/Section:

Address:

City

State

Zip Code+4

Telephone Number:

-

-

Ext:

(Area code required)

Email Address:

Please contact me at:

Residential Contact

Work/School Contact

Section 4. Education, Training, and Licensure

Important: Please attach your Curriculum Vitae and be sure to list significant honors in your CV. Limit the body of the Curriculum Vitae to two pages with an optional page to list publications, patents, etc., if applicable.

Undergraduate Degree (1):

Year

Degree

Major/Field of Specialization:

Conferring Institution:

Undergraduate Degree (2):

Year

Degree

Major/Field of Specialization:

Conferring Institution:

Doctor of Veterinary Medicine: (or Equivalent Degree)

Accredited by AVMA*?

 Yes  No

Year

Degree

Major/Field of Specialization:

Conferring Institution:

* The Veterinary College where you obtained your DVM (or equivalent) must be accredited by the AVMA. Visit the AVMA website for a full list of accredited schools: http://www.avma.org/education/cvea/colleges_accredited/allcolleges.asp

Instructions for Doctor of Veterinary Medicine or Equivalent Specialty and Subspecialty Training: Select the area(s) in which you have specialty or subspecialty training and indicate whether you are board eligible or certified in that area.

Specialty (optional):

Board Eligible:

 Yes  No

Board Certified:

 Yes  No

Date certified

Subspecialty (optional):

Board Eligible:

 Yes  No

Board Certified:

 Yes  No

Date certified

Graduate Degree (1):

Year

Degree

Major/Field of Specialization:

Conferring Institution:

If Ph.D., please attach a synopsis of your dissertation abstract. Please limit to 5,000 characters, approximately two double-spaced pages.

Graduate Degree (2):
	Year		Degree
Major/Field of Specialization:
Conferring Institution:
Graduate Degree (3):
	Year		Degree
Major/Field of Specialization:
Conferring Institution:

Internship:	 Yes  No
			Program Name			Start Date		Completion Date
			Institution/Location
Residency:	 Yes  No
			Program Name			Start Date		Completion Date
			Institution/Location
Current Veterinary license(s):
			State			Expiration Date
USDA APHIS Accreditation:	 Yes  No
			Accreditation Date

In the space below, list any other relevant training program, courses of study, licensures, or professional certifications (requiring greater than 8 hours of direct applicant participation). Be sure to include the name of program and a brief description/synopsis, including date completed, date of expiration (if applicable), and credential earned (if applicable):

Section 5. Service Obligation

Note: If you have a service obligation, you may still be eligible for VMLRP consideration if your service obligation has been or can be deferred for the entire period of your VMLRP contract. For assistance, please contact VMLRP staff at [email protected].

Do you owe a service payback obligation?



Yes (Continue with questions below)



No (Skip to Section 6)

Program Name:

When do you expect to fulfill your obligations?

Month

Day

Year

Section 6. Voluntary Disclosures

Completion of items in this section is VOLUNTARY. The information provided will be used to measure the extent to which members of these groups are applying for and/or receiving VMLRP contracts and/or for program evaluation. Failure to answer these questions will not have an effect on your application.

How did you learn about the VMLRP?

Age:

Gender:



Female



Male

(Select one)

Ethnicity: (Select one)

 

Hispanic or Latino Not Hispanic or Latino

A person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish cultures or origins, regardless of race.

Race: (Select one or more)



American Indian or Alaska Native

A person having origins in any of the original peoples of North or South America (including Central America), and who maintains tribal affiliation or community attachment.



Asian

A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.



Black or African American

A person having origins in any of the black racial groups of Africa.



Native Hawaiian or Other Pacific Islander

A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.



White

A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.



I do not wish to provide this information

A person is disabled if he or she has a physical or mental impairment which substantially limits one or more major life activities, has a record of such impairment, or is regarded as having such impairment.

Disability: (Check all that apply)



I do not have a disability



Deaf



Convulsive disorder



Blind



Mental retardation



Missing extremities



Mental or emotional illness



Partial paralysis



Severe distortion of limbs and/or spine



Complete paralysis



I have a disability, but it is not listed

Section 7. Certifications

Certification of Non-delinquent Status

The Federal Debt Collection Procedures Act of 1999 precludes a debtor who has a Federal judgment lien against his/her property arising from a Federal debt from receiving Federal funds until the judgment is paid in full or otherwise satisfied. Applicants for the NIFA Veterinary Medicine Loan Repayment Program must certify that they do not have a judgment lien against their property arising from a debt to the United States.

I hereby certify that I		do		do not	have a judgment lien against my property arising from a debt to the United States
I hereby certify that I		am		am not	delinquent on any debt to the United States

Certification of Accuracy of Information Provided

	I certify that the information given in this application is true, complete, and accurate to the best of my knowledge and does not omit any material fact that would render the statement false, fictitious, or fraudulent as a result of the omission. I understand that the information given may be investigated and that any false representation is sufficient cause for rejection of the application, or, if awarded loan repayment, that I am liable for return of all awarded funds and, further, that any false statement may be punished as a felony under U.S. Code, Title 18, Section 1001. I am aware that any false, fraudulent, or fictitious statement may, in addition to other remedies available to the Government, subject me to civil penalties under the Program Fraud Civil Remedies Act of 1986.
	I authorize any program to which I owe a service obligation to release information about that obligation to administrators of the NIFA VMLRP and to other authorized Government officials.

Public reporting for collection of information is estimated to average 60 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the date needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to NIFA, OEP, 800 9^th St. SW, Washington, DC 20024, Attention Policy Section. Do not return the completed form to this address.

NIFA Form 01-10

OMB No. 0524-0047

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