Application Part 1 Application Part 1

_NIFA Veterinary Medicine

Loan Repayment Program (VMLRP)

APPLICATION PART 1: PROGRAM

National Institute of Food and Agriculture US Department of Agriculture

OMB No. 0524-0050

Form Approved For Use Through XX/XX/XXXX

Purpose: This form is to be completed by applicants to USDA’s Veterinary Medicine Loan Repayment Program, authorized by the National Veterinary Medical Services Act, to help qualified veterinarians offset the educational debt incurred from receiving their veterinary medical degrees, in return for service in veterinary shortage situations.

Instructions: Complete the sections below. Submit this application according to the instructions detailed in the Notice of Funding Opportunity prior to the application deadline. For additional information to prepare your application documents, visit the VMLRP Applicant’s website (https://www.nifa.usda.gov/grants/programs/veterinary-medicine-loan-repayment-program/vmlrp-applicants).

Section 1. Identifying Information

1. Application Type:  NEW (individual who is not a current or previous VMLRP

awardee)

• RENEWAL (individual applying to continue serving the original awarded shortage area)

2. Applicant’s Name:

First Middle Last Suffix

3. Other Names Used:

(e.g. maiden name)

Check the Veterinary Services Shortage Situations Map for the for the Shortage Identification Code of the shortage area (State Abbreviation year, i.e. MO252) to which you are applying. The Shortage Identification Code entered on this form MUST match the code entered on the Intent of Employment form section 8. An applicant may apply to only ONE shortage situation code of the shortage area (State Abbreviation year, i.e. MO252) to which you are applying. The Shortage Identification Code entered on this form MUST match the code entered on the Intent of Employment form Section 8. An applicant may apply to only ONE shortage situation.

4. Enter the Shortage Identification Code:

5. Shortage Type (Mark ^{one box):}

   • ^{Type I: Private Practice (80% FTE commitment)}

   • Type II: Private Practice – Rural Area (minimum 30% to maximum 80%FTE commitment)

   • Type II: Public Practice (minimum 49% to maximum 80% FTE commitment)

Section 2. Personal Contact Information

1. Residential Address: ^Street

City State Zip Code

2. Personal Phone Number:

(Area code required)

3. Personal Email

Address:

Section 3. Employment Contact Information

1. Position Title: 2. Organization/Practice:

3. Division/School: 4. Department/Section:

5. Address:

Street

City State Zip Code+4

5. Work Telephone

Number: Ext:

(Area code required)

5. Work Email

Address:

Section 4. Education, Training, and Licensure

Important: Include in the application package a maximum two-page Resumé describing your professional education and experience. An additional page may be submitted to highlight publications, patents, conference presentations, book chapters, etc. If Ph.D., attach a synopsis of your dissertation abstract limited to approximately two double-spaced pages.

Pre-veterinary Medical Education:

1. Undergraduate

Degree (1):

Year Degree

Major/Field of

Specialization:

Conferring

Institution:

2. Undergraduate

Degree (2) or Graduate Degree:

Major/Field of Specialization:

Conferring Institution:

3. Doctor of Veterinary Medicine:

(or Equivalent Degree)

Year Degree

Accredited by Yes

AVMA*?  No

Year:

Degree:

Conferring Institution:

*The Veterinary College where you obtained your DVM (or equivalent) degree must be accredited by the AVMA to be eligible to apply to the VMLRP. Visit the AVMA website for a full list of accredited schools: https://www.avma.org/education/center-for-veterinary-accreditation/accredited- veterinary-colleges.

Post Veterinary Medical Graduate or Specialty Training (Internship, Residency, Post- Doctoral Appointments, etc.): Provide the area(s) in which you have post-DVM graduate or specialty training and indicate whether you are board-eligible or -certified in that area.

4. Primary

Specialty:

Board Eligible: ☐ Yes Board Certified: ☐ Yes

No ☐ No Date Certified

5. Secondary Specialty:

Certifying Board or College (If applicable)

Board Eligible: ☐ Yes ^{Board Certified: ☐ Yes}

• No

• No

Date Certified

Certifying Board or College (If applicable)

6. Graduate

Degree (1):

Year Degree

Major/Field of

Specialization:

Conferring

Institution:

7. Graduate

Degree (2):

Year Degree

Major/Field of

Specialization:

Conferring

Institution:

8. Residency: Yes

• No

Program Name Start Date Completion Date

9. Internship: ^Yes

Institution/Location

• No

Program Name Start Date Completion Date

Institution/Location

10. Current

Veterinary License(s):

• Yes*

• No

• Pending

• N/A

State State State State

Expiration Date Expiration Date Expiration Date Expiration Date

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11. USDA APHIS

Accreditation: ^{ Yes*}

• No

• Pending

• N/A

Accreditation Expiration Date

*If you answered “Yes” attach a PDF copy of current veterinary license(s) and/or USDA APHIS Accreditation.

Other Relevant Training

12. In the space below, list any other relevant training programs, courses of study, licensures, or professional certifications (requiring greater than 8 hours of direct applicant participation). Include the name of program and a brief description/synopsis, including date completed, date of expiration (if applicable), and credential earned (if applicable) (600-character limit):

Section 5. Service Obligation If you have an obligation, to provide veterinary medical services to another entity in exchange for repayment of educational loans you may still be eligible for VMLRP consideration. For assistance, please contact VMLRP staff at [email protected].

1. Do you have a _ Yes (Continue with questions

service payback

obligation?

below)

• No (Skip to Section 6)

2. Program Name:

3. When do you expect to

fulfill your obligation?

Month Day Year

Section 6. Certifications

1. 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. As the applicant, I hereby certify to the best of my knowledge and belief that:

1. I am not presently debarred, suspended, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency.

2. I have not been convicted or had a civil judgment rendered against me within a three-year period preceding this application for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transition; or commission of embezzlement, theft, forgery, bribery, falsification, or destruction of records, making false statement, or receiving stolen property.

3. I do not have a judgment lien against my property arising from a debt to the United States.

4. I am not delinquent on any debt to the United States.

2. Certification of Accuracy of Information Provided

^{I certify the information provided 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 because of the omission. I understand the information provided may be investigated and 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 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 for veterinary medical services to release information about that obligation to administrators of the NIFA VMLRP and to other authorized government officials.

3. Release to Contact Recommenders

I certify that I am requesting recommendation(s) from individual(s) of my choice 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 and merit for participation in the VMLRP. I understand that the recommendations 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 and merit for participation in the VMLRP.

4. Voluntary Waiver of Future Rights to Access Confidential Recommendations

I understand that I will not have access to the recommendations based on the statement of confidentiality contained in the “Release to Contact Recommenders” section above.

Signature of Applicant Date

Section 7. Voluntary Participant Disclosure Instructions: If awarded, NIFA may disclose participation of an awardee’s name, contact information, biography, professional details and image as indicated below with one or several options for the awardee to select. Such use includes the display, distribution, publication, transmission, or otherwise use of this information in materials that include, but may not be limited to the program website, as well as printed materials such as brochures, newsletters, videos or digital images. Such use of the awardee’s information involves the awardee’s selection of the following options:

☐I grant permission to share my professional information for VMLRP awardee “success stories” featured on the NIFA or VMLRP program website.

☐I grant permission to share my name and contact information with the State Animal Health Official in the state(s) I am awarded to serve.

☐I grant permission to share my name and contact information with professional veterinary organizations such as the American Veterinary Medical Association (AVMA) to promote rural food animal veterinary medicine.

☐I request to be contacted directly by NIFA for written approval before sharing my information.

☐I deny permission to share my information in any way.

Signature of Applicant Date

Section 8. Intent of Employment Instructions: Complete Employment Contact Information for the hiring official who can provide verification of intent to offer you employment, including the time and resources for you to conduct your proposed service, in a veterinarian

shortage situation. Certification of employment must be completed by the hiring official. This intent to offer is not legally binding but should represent a good faith expectation that the probability of employment is high. If you are self-employed or intending to start your own practice, you may list yourself as the hiring official.

Employment Contact Information: The applicant must obtain information needed to complete this section from the appropriate authorized hiring official for the practice or organization. If you are, or expect to be, the owner of the practice you will be working at, then you will be the hiring official for the purposes of the contact information requested below.

Applicant Name:

I am currently the owner/hiring official of the practice. I intend to establish a new practice that I will own.

I am employed by a public entity or private practice.

I intend to be employed by a public entity or a private practice.

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 Shortage Identification Code entered on page one of this application.

Enter the Shortage Identification Code:

Contact Information for the Prospective Employer/Hiring Official

Practice/Organization:

Address:

Name of Hiring Official:

Email Address:

Telephone Number(s):

Certification of Employment: This section is to be completed by the hiring official identified in the Contact Information for the Prospective Employer/Hiring Official.

I certify that the applicant identified above will be provided the necessary time and resources to perform qualified veterinary services, in accordance with the terms and conditions of their agreement with the Secretary of Agriculture, for the practice/organization identified in this section for a minimum of three years from the date a VMLRP contract is initiated, assuming satisfactory performance of duties by the applicant. I further certify that the information provided on this form is accurate to the best of my knowledge. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.

Signature of Hiring Official Date

If at any point during the period of this award, this individual ceases to be employed by your organization, you may inform the VMLRP of this change at [email protected].

Public reporting for collection of information is estimated to average 3 hours, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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, OGFM, 2312 East Bannister Road, Mail Stop 10,000, Kansas City, MO 64131, Attention Policy Section. Do not return the completed form to this address.

OMB No. 0524-0050

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NIFA invests in and advances agricultural research, education, and extension and promotes transformative discoveries that solve societal challenges.

USDA is an equal opportunity lender, provider and employer.