Form NIFA-03-10 List of Recommenders

Name:

NIFA Veterinary Medicine
Loan Repayment Program (VMLRP)

List of Recommenders

National Institute of Food and Agriculture
US Department of Agriculture
NIFA-03-10
OMB No. 0524-0050
Form Approved For Use Through TBD

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

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?

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Suffix

Name:
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 9th St. SW, Washington, DC
20024, Attention Policy Section. Do not return the completed form to this address.
NIFA Form 03-10
OMB No. 0524-TBD

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