NIFA -06-10 Certification for Application

Name:

NIFA Veterinary Medicine
Loan Repayment Program (VMLRP)

Certifications for Application

National Institute of Food and Agriculture
US Department of Agriculture
NIFA-06-10
OMB No. 0524-NEW
Form Approved For Use Through TBD

NIFA Veterinary Medicine Loan Repayment Program
Instructions: Please print, sign and mail this form with your application.
Section 1. Certification by Applicant/Borrower
I hereby apply to enter into an agreement with the Secretary of USDA for repayment of the educational loan listed in my
application, incurred solely for the costs of education, including reasonable living expenses, of attending a college of veterinary
medicine accredited by the AVMA Council on Education. I hereby certify that the information given 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 as a result of the omission. I am aware that 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 hereby authorize the lending institution, servicing agent, and/or institutional program named in my application
to release information about my loan or any loan owned, serviced, or administered by my lending institution, servicing agent,
or program administrator to the administrators of the NIFA Veterinary Medicine Loan Repayment Program (VMLRP) and other
authorized Government officials. This authorization shall remain in effect during my application and participation in the NIFA
VMLRP, and 120 days after completion of VMLRP contracted service or 18 months after the Secretary determines I am in
breach of this agreement, whichever is applicable.
Print Name

Signature

Date

Section 2. Application’s Certification of Accuracy of Information Provided
I certify that the information given 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 as a result of the omission. I understand
that the information given may be investigated and that any false representation is sufficient cause for rejection of this
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 18 U.S.C. § 1001. I am aware that 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 to release information about that obligation
to administrators of the NIFA VMLRP and other authorized Government officials.
Print Name

Signature

Date



Section 3. Applicant’s Request for Confidential Recommendations
I certify that I am requesting recommendation(s) from individual(s) of my choosing that will be included in my NIFA VMLRP
application. My application, including the completed recommendation forms submitted by my recommenders, will be used by
NIFA officials to determine my eligibility for participation in the VMLRP. I understand that the recommendation(s) I am
requesting shall be held in confidence and protected from disclosure by officials of the NIFA VMLRP according to Privacy Act
System of Records (see Confidentiality and Privacy Act Notice in this application package). I authorize administrators of the
NIFA VMLRP and other authorized Government officials to contact the individual(s) I have identified to request and additional
information that may be needed in determining my eligibility for participation in the VMLRP.
Print Name

Signature

Date

Public reporting for collection of information is estimated to average 15 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 06-10
OMB No. 0524-NEW

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