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

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 05790353. The time required to complete this information collection is estimated to average .33 hours per response, including the time for
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collection of information.

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

OMB APPROVED
0579-0353
EXP. XX/XXXX

NOMINATION REQUEST FORM

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:

CELL PHONE NUMBER (Government or Business):

WORK EMAIL ADDRESS:

CHECK ONE:

FEDERAL EMPLOYEE

STATE EMPLOYEE

OTHER

AGENCY/ORGANIZATION:

JOB TITLE:

PARTICIPANT'S OFFICIAL DUTY STATION:

SUPERVISOR’S NAME:

SUPERVISOR’S EMAIL ADDRESS:

SUPERVISOR'S APPROVAL:

APHIS OFFICIAL'S APPROVAL:

EMAIL THE COMPLETED NOMINATION FORM TO THE PROFESSIONAL DEVELOPMENT SERVICES (PDS) AT
PROFESSIONAL.DEVELOPMENT.STAFF@APHIS.USDA.GOV. POINT OF CONTACT FOR TRAINING.

A LIST OF THE PDS POINTS OF CONTACT FOR TRAINING CAN BE FOUND ON THE WEB AT:
http://www.aphis.usda.gov/wps/portal/aphis/ourfocus/animalhealth?1dmy&urile=wcm%3apath%3a%2Faphis_content_library%2Fsa_our_fo
cus%2Fsa_animal_health%2Fsa_training_and_development%2Fsa_professional_development

VS FORM 1-5
OCT 2018