Form-03-10 List of Recommendaters

Name:

	NIFA Veterinary Medicine Loan Repayment Program (VMLRP)	National Institute of Food and Agriculture US Department of Agriculture NIFA-03-10 OMB No. 0524-0047
List of Recommenders
NIFA Veterinary Medicine Loan Repayment Program

Instructions: Your application requires that you obtain three complete recommendations. Please provide the name, email address, and phone number for the individuals who will provide a recommendation for your application.

It is your responsibility to ask recommenders identified on this form to complete a recommendation form on your behalf. We can only accept recommendations via the NIFA-08-10 form. Other forms of recommendations are not acceptable.

Section 1. Required Recommendations

Applicant’s Name:
	First Name	Middle Name	Last Name	Suffix

Recommender #1

Name:
	First Name		Last Name
Email Address:
Phone Number:
	(Area code required)
In what capacity do you know the recommender?

Recommender #2

Name:
	First Name		Last Name
Email Address:
Phone Number:
	(Area code required)
In what capacity do you know the recommender?

Recommender #3

Name:
	First Name		Last Name
Email Address:
Phone Number:
	(Area code required)
In what capacity do you know the recommender?

Section 2. Release and Waiver

Release to Contact Recommenders

I certify that I am requesting recommendation(s) from individual(s) of my choosing that will be included in my Veterinary Medicine Loan Repayment Program (VMLRP) application. My application, including the completed recommendation forms submitted by my recommenders, will be used by USDA officials to determine my eligibility for participation in the VMLRP. I understand that the recommendation I am requesting shall be held in confidence and protected from disclosure by officials of the VMLRP according to Privacy Act System of Records (see Confidentiality and Privacy Act Notice). I authorize administrators of the VMLRP and other authorized Government officials to contact the individual(s) I have identified to request any additional information that may be needed in determining my eligibility for participation in the VMLRP.

Voluntary Waiver of Future Rights to Access Confidential Recommendations

I understand that I will not have access to the recommendations based on the promise of confidentiality made to my recommenders in Section 3.

Signature		Date

Public reporting for collection of information is estimated to average 30 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 03-10

OMB No. 0524-0047

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