NIFA-08-10 Recommendation Form

	NIFA Veterinary Medicine Loan Repayment Program (VMLRP)	National Institute of Food and Agriculture US Department of Agriculture NIFA-08-10 OMB No. 0524-0047
Recommendation Form
NIFA Veterinary Medicine Loan Repayment Program

Instructions: Please provide the following information and send it to NIFA by email at [email protected] or fax at (202) 720-6486. Please retain a copy in case delivery failure requires resubmission of this form.

Section 1. Recommender Information

Recommender’s Name:
	First Name	Middle Name	Last Name	Suffix
Relationship to Applicant:
Position/Title:
Organization:
Work Address:
	City		State	Zip Code+4
Telephone Number:
	(Area code required)
Email Address:

Section 2. Applicant Information

Applicant’s Name:
	First Name	Middle Name	Last Name	Suffix
How long have you known the applicant? (include approximate dates)
	(Please limit your response to 50 characters)

Section 3. Recommendation

Instructions: All fields on this form are required. You may elect to cut and paste text from another document into the text fields. If you have no further information to add to a question, please indicate “No Comment” or “N/A”.

Select the rating that best indicates your assessment of the applicant in relation to his/her peers.

Rating of Applicant	Outstanding		Average		Poor	Don’t Know
	1	2	3	4	5
Previous training and experience to serve in the veterinary shortage situation applied for:
Career goals and plans to achieve these goals:
Commitment to providing veterinary services similar to those needed to fill this shortage:
Potential for success operating a single-practitioner veterinary practice:
Civic mindedness:
Interpersonal skills:
Critical thinking/Problem solving skills:
Overall assessment of applicant:

Short Answers: Please limit your response to 2,000 characters (approximately one double-spaced typed page) for each question.

What are the main strengths and weaknesses that the applicant brings to his/her work environment?

What is your assessment on the applicant’s practice plans and logistics relative to the specific shortage situation he/she is applying for?

What is your overall recommendation for the applicant?

Section 4. Certification of Recommendation

I certify that the statements herein are true, accurate, and complete.

Signature		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 08-10

OMB No. 0524-0047

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