HPI Online Application Template (20240628)

Paperwork Reduction Act 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 0579-0490.  The time required to complete this information collection is estimated to average 1 hour 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.

0579-0490 Approved Exp. XX/XXXX

Horse Protection Inspector (HPI) Application Template

Introduction paragraph/instructions

APPLICANT INFORMATION

First name ______________________ MI _____ Last Name________________________

Address 1: ________________________________________________________________

Address 2: ________________________________________________________________

City: _______, State: (state dropdown) Zip: _(number field)________

Phone: __________________________ Email: _____________________________

How did you hear about this position? ___________________________________________

QUALIFICATIONS

Tier 1 Qualifications (*must be met for USDA to evaluate the application*)

Are you a veterinarian? ○Yes ○No

IF NO – If you are not a veterinarian, are you a Veterinary Technician or otherwise employed by State or local government agencies to enforce laws/regulations pertaining to animal welfare (ie: Animal Control Officer, Animal Welfare Officer, etc)? ○Yes ○No

If yes, what is your Official Title? ______________________________________________________
Ex: If your title is Veterinary Technician, please specify if you are a Registered Veterinary Technician, Certified Veterinary Technician, Licensed Veterinary Technician, Specialized, etc.

If No, please provide an explanation: ___________________________________________________

Note: Veterinary Technicians will need to submit academic transcripts with this application.

Note: If you are a Veterinary Technician, you will need to submit your academic transcripts with this application.

IF YES to Veterinarian

Are you currently licensed to practice veterinary medicine? Yes/No

Which State, are you licensed to practice: State Dropdown (can select multiple states)

License number(s)_______________________________________________________________

Note: You will need to submit your academic transcripts with this application.

Hide/Show based on user selection:

EMPLOYER INFORMATION

Name of Current Employer: ________________________________________________________

Employer Address: _______________________________________________________________

Employer Phone Number: _________________________________________________________

Name of Immediate Supervisor: ____________________________________________________

Phone Number of Immediate Supervisor: ____________________________________________

Do you grant permission for your supervisor to be contacted to verify Title and Employment status? ○Yes ○No

Tier 2 Qualifications

Comment Box

Please state, if any, prior experience working with the Horse Protection Act or enforcing the Horse Protection Act and its regulations.

Comment Box

Please state equine experience, including husbandry and care of as well as knowledge of equine science, health, and welfare. Please specifically include any experience, as well as length of time of that experience, that would be used to help in the identification of soring or soring practices.

Have you ever been found to have violated any provision of the Horse Protection Act or its regulations?

IF YES = Show Comments Box for explanation

○Yes ○No

IF YES = Show Comments Box for explanation

Have you ever been assessed any civil penalty or have been the subject of a disqualification order in a proceeding involving an alleged violation of the Horse Protection Act or regulations? ○Yes ○No

IF YES = Show Comments Box for explanation

Have you ever been disqualified by the U.S. Department of Agriculture from performing diagnosis, detection, and inspection under the Horse Protection Act? ○Yes ○No

Horse Protection Inspectors must not have acted in a manner that calls into question the applicant’s honesty, professional integrity, reputation, practices, and reliability. As an HPI applicant, do you authorize APHIS to obtain and review:

1. Criminal conviction records, if any. _______ (e-initials)

2. Official records of applicant’s actions while participating in Federal, State, or local veterinary programs, including veterinary board complaints, if any. ________ (e-initials)

3. Judicial determinations in any type of litigation, if any. _______ (e-initials)

I certify that the information provided herein is true and correct to the best of my knowledge. I certify that I am 18 years of age or older. I understand that my application for authorization as a Horse Protection Inspector may be denied for any of the reasons outlined in §11.19(a). I also understand that prior to authorization, I must successfully complete a formal HPI training program administered by APHIS and that authorization may be permanently disqualified if I am found to have failed to inspect horses in accordance with the procedures prescribed by APHIS or otherwise failed to perform the duties necessary for APHIS to enforce the Horse Protection Act and regulations.

e-SIGNATURE

____________________________________________________________

Printed Name

__________________________________________________________ _________________

Signature Date

ATTACHMENTS = Required if Veterinarian or Veterinary Technician

Submit Button = [email protected]

Example submission note to applicant.
“Thank you for your application. We will review and get back to you. If you have any questions, please contact us at [email protected]”