VS 4-11 NVSL Application for Laboratory Training

Clear Form
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 0579-0430. The time required to complete this information collection is estimated to average 15
minutes 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. Send comments regarding this burden statement or any other aspect of this information collection, including suggestions for reducing this burden, to [email protected].

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES

OMB Approved
0579-0430
Exp. XX/XXXX

NVSL Application for Laboratory
Training

National Veterinary Services Laboratories
1920 Dayton Avenue
P.O. Box 844
Ames, IA 50010
1. Name and Address of Applicant (Type or Print)
Dr., Mr., Mrs., Ms.:
Last Name:

Telephone Number: 515-337-7475/7300
Fax Number: 515-337-7716
Email: [email protected]
First Name:

Middle Initial:

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:

Authorizing Official’s Signature (If nomination is for EIA training, VS Assistant District Director must sign here):

Date:

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

Phone Number:

VS FORM 4-11
MAY 2015