NIFA -01-10 Applicant Information

NIFA Veterinary Medicine
Loan Repayment Program (VMLRP)

National Institute of Food and Agriculture
US Department of Agriculture
NIFA-01-10
OMB No. 0524-NEW
Form Approved For Use Through TBD

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

Telephone Number:
Fax Number:
(optional)
Email Address:

State

-

-

-

-

(Area code required)

(Area code required)

Zip Code+4

Name:______________________________

Shortage ID:_______________
 NEW
 RENEWAL

Section 3. Current Employment Contact Information
Position Title:

Organization/Practice:

Division/School:

Department/Section:

Address:

City

Telephone Number:

State

-

-

(Area code required)

Zip Code+4

Ext:

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

Year

Degree

Major/Field of Specialization:
Conferring Institution:

Undergraduate Degree (2):
Major/Field of Specialization:
Conferring Institution:

Doctor of Veterinary Medicine:
(or Equivalent Degree)

Year

Degree

Accredited  Yes
by AVMA*?  No

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

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Name:______________________________

Shortage ID:_______________
 NEW
 RENEWAL

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

Board Certified:

 Yes
 No

Date certified

Subspecialty (optional):
Board Eligible:

Graduate Degree (1):

Year

 Yes
 No

Date certified

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

Year

Degree

Major/Field of Specialization:
Conferring Institution:

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

Internship:

 Yes
 No

Program Name

Start Date

Institution/Location

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Completion Date

Name:______________________________

Residency:

 Yes
 No

Shortage ID:_______________
 NEW
 RENEWAL

Program Name

Start Date

Completion Date

Institution/Location

Current Veterinary
license(s):
USDA APHIS
Accreditation:

State

Expiration Date

 Yes
 No
Accreditation Expiration 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

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Year

Name:______________________________

Shortage ID:_______________
 NEW
 RENEWAL

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:
(Select one)



Female

Ethnicity:
(Select one)



Hispanic or Latino



Not Hispanic or Latino



American Indian or Alaska
Native



Asian



Black or African American



Native Hawaiian or
Other Pacific Islander



White



I do not wish to provide this information

Race:
(Select one or more)

 Male
A person of Mexican, Puerto Rican, Cuban, South or
Central American, or other Spanish cultures or
origins, regardless of race.
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.
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.
A person having origins in any of the black racial
groups of Africa.
A person having origins in any of the original
peoples of Hawaii, Guam, Samoa, or other Pacific
Islands.
A person having origins in any of the original
peoples of Europe, the Middle East, or North Africa.

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

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Name:______________________________

Shortage ID:_______________
 NEW
 RENEWAL

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 9th St. SW, Washington, DC
20024, Attention Policy Section. Do not return the completed form to this address.
NIFA Form 01-10
OMB No. 0524-NEW

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