VS 4-11 NVSL Application for Laboratory Training

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-XXXX. The time
required to complete this information collection is estimated to average .25 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.

United States Department of Agriculture
Marketing and Regulatory Programs
Animal and Plant Health Inspection Service
Veterinary Services

OMB Approved
0579-XXXX
Exp.: XX/XXXX

NVSL Application for Laboratory Training

National Veterinary Services Laboratories
1800 Dayton Avenue
P.O. Box 844
Ames, IA 50010
1. Name and Address of Applicant (Please Type or Print)
(Dr., Mr., Mrs., Ms.,) (Last)

Telephone Number: 515-337-7475/7501
Fax Number: 515-337-7332
Email: [email protected]
(First)

(MI)

Office Address:

City:

State:

Office Telephone Number:

ZIP Code:

Country:

Fax Number:

Email Address:

2. Training Desired
Course Name:

Date (If Known):

Cost:

3. Employer
Organization:

Division/Unit:

Local Address:

City:

4. Professional Status
Occupation:

State:

Position Title:

ZIP Code:

Specialty:

Brief description of your previous experience or training in conducting the requested test(s).

5. Signatures
Applicant’s Signature:

Date:

(If nomination is for EIA training, AVIC must sign here) - Authorizing Official’s Signature:

Date:

Name/Title of Authorizing Official (Print of Type):

Phone Number:

VS 4-11
JULY 2014