Form VS 1-5 VS 1-5 Nomination Request Form

According to the Paperwork Reduction Act of 1995, no persons are 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 requ ired to complete this information collection is estimated to average 1 hour pe r response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the co llection of
information.

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

FORM APPROVED
OMB NO.
0579-XXXX

NOMINATION REQUEST FORM

** This section to be completed by the Training Coordinator**
PRIORITIZED NUMBER:____________________________________________________________
COURSE TITLE:

DATE OF THE COURSE:

PARTICIPANT'S NAME (DR., MR., MS., MRS.):

MAILING ADDRESS (street, city, state, zip code, and country):

WORK PHONE NUMBER:

WORK FAX NUMBER:

(Government or Business) CELL PHONE NUMBER:

WORK E-MAIL ADDRESS:

CHECK ONE:

FEDERAL EMPLOYEE

STATE EMPLOYEE

OTHER

AGENCY/ORGANIZATION:

JOB TITLE:

PARTICIPANT'S OFFICIAL DUTY STATION:

SUPERVISOR'S APPROVAL:

REGION'S APPROVAL:

PLEASE FAX THE COMPLETED NOMINATION FORM TO YOUR TRAINING COORDINATOR. THE TRAINING COORDINATOR WILL FAX TO
THE PROFESSIONAL DEVELOPMENT STAFF.

A LIST OF TRAINING COORDINATORS CAN BE FOUND IN THE VETERINARY SERVICES TRAINING CATALOG ON THE WEB AT:
HTTP:/WWW.APHIS.USDA.GOV/ANIMAL_HEALTH/PROF_DEVELOPMENT/

VS FORM 1-5
(NOV 2007)