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

Nomination Request Form - Animal Disease Training

VS 1-5 AUG 2014

Nomination Request Form: Animal Disease Training (State, Local or Tribal Government)

OMB: 0579-0353

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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 .33 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 is 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:

CELL PHONE NUMBER (Government or Business):

WORK EMAIL ADDRESS:

CHECK ONE: FEDERAL EMPLOYEE STATE EMPLOYEE OTHER

AGENCY/ORGANIZATION:

JOB TITLE:

PARTICIPANT'S OFFICIAL DUTY STATION:

SUPERVISOR'S APPROVAL:

APHIS OFFICIAL'S APPROVAL:


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



A LIST OF THE POINTS OF CONTACT FOR TRAINING CAN BE FOUND ON THE WEB AT:

http://www.aphis.usda.gov/wps/portal/aphis/ourfocus/animalhealth?1dmy&urile=wcm%3apath%3a%2Faphis_content_library%2Fsa_our_focus%2Fsa_animal_health%2Fsa_training_and_development%2Fsa_professional_development





VS FORM 1-5

AUG 2014

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Authorsmharris
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File Created2021-01-25

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