NIFA-07-10 Intent of Employment

Name:

	NIFA Veterinary Medicine Loan Repayment Program (VMLRP)	National Institute of Food and Agriculture US Department of Agriculture NIFA-07-10 OMB No. 0524-0047
Intent of Employment
NIFA Veterinary Medicine Loan Repayment Program

Instructions: This form is to be completed by new applicants only. New applicants are defined as individuals who have not received a VMLRP award before. Please complete Section 1 with contact information for an official who can provide verification of intent to offer you employment, including the time and resources to conduct your proposed service, in a veterinarian shortage situation. Section 2 must be completed by the hiring official identified in Section 1. This intent to offer is not legally binding but should represent a good faith expectation that the probability of employment is high.

Section 1. Contact Information (to be completed by applicant)

Important: The applicant must obtain information needed to complete this section from the appropriate authorized hiring official for the practice or organization. If you are, or expect to be, owner of the practice you will be working at, then you will be the hiring official for the purposes of the contact information requested below.

Applicant Name:

	I am currently owner/hiring official of the practice I will work in.
	I intend to establish a new practice I will own, serve as hiring official for, and work in.
	I work or intend to work in a public position or a private practice owned by someone else.

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 Applicant Information form (NIFA-01-10).
Please enter the five-character Shortage Identification Code:

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

Contact Information for the Prospective Employer/Hiring Official
Practice/Organization:
Address:
Name of Hiring Official:
Email Address:
Telephone Number(s):

Section 2. Certification of Employment (to be completed by hiring official)

Important: This section is to be completed by the hiring official identified in Section 1.

I certify that the applicant identified above will be provided the necessary time and resources to perform qualified veterinary services, in accordance with the terms and conditions of his/her agreement with the Secretary of Agriculture, for the practice/organization identified in Section 1 for a minimum of three years from the date a VMLRP contract is executed (January 2015), assuming satisfactory performance of duties by the applicant. I further certify that the information provided on this form is accurate to the best of my knowledge. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.

Signature of Hiring Official (sign your full name in ink)		Date

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 07-10

OMB No. 0524-0047

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