VS Form 9-23 Auditor Application For USDA-APHIS-VS-NPIP AI Clean Comp

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 of this information collection is 0579-0007. The time required to complete this information collection is estimated to
average 1 hour 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.

Auditor Application for USDA-APHIS-VS-NPIP
AI Clean Compartment Program

Instructions: Applicants, please complete sections A, B, and C and sign and date application. Applicant
must have a qualified sponsor complete Section D and attach a letter of recommendation. Completed application
must be submitted to the NPIP. After NPIP review, each applicant will receive notice of approval or denial.

A. Background Information. To be completed by candidate seeking auditor certification.
Personal Information
Name of Applicant:
Business Address (Physical
Location with City, State, and
Zip):
Home Address (Physical
Location with City, State, and
Zip):
Telephone Number:
Alternate Phone Number:
Fax Number:
Email Address:
Qualifications
Colleges/Institutions where
degrees earned:
Major (Minor):
Degrees:
Veterinary License Number:
Are you a United States
Citizen?
Are you a Federal VMO?
Are you accredited by the
NVAP?
Are you a member in good
standing with the American
College of Poultry
Veterinarians?
Estimated years of poultry
experience (not including
school-related experiences)

VS FORM 9-23
OCT 2018

 Yes

No

 Yes

No

 Yes

No

 Yes

No

 <1  1-5  5-10  >10

OMB Approved
0579-0007
EXP: XX/XXXX

B. REASON FOR INTEREST. To be completed by candidate seeking auditor certification.
To be eligible for admission into the auditor training workshop course, you must briefly describe your
interest in the program and the qualifications you possess that you feel will allow you to become a
successful auditor.

C. Affidavit.

To be completed by candidate seeking auditor certification. Please place a check mark
by the answer that applies.
YES
I certify that I do not own birds of any avian species, whether for meat, eggs,
sale, resale, pet, hobby, or otherwise.
I certify that I have not been employed by, nor do I have spouse, relative, or
household member employed by or in contractual relations with any of the
companies that belong to the U.S. AI Clean Compartment Program.
I certify that I will uphold the U.S. veterinarian’s oath in all interactions, which
states: Being admitted to the profession of veterinary medicine, I solemnly
swear to use my scientific knowledge and skills for the benefit of society
through the protection of animal health and welfare, the prevention and relief
of animal suffering, the conservation of animal resources, the promotion of
public health, and the advancement of medical knowledge. I will practice my
profession conscientiously, with dignity, and in keeping with the principles of
veterinary medical ethics. I accept as a lifelong obligation the continual
improvement of my professional knowledge and competence.
I certify that I have never been convicted of a felony.
I certify that I have never had my veterinary license revoked by any State
board of veterinary medicine.

NO

D. Verification. To be completed by sponsor.
To be considered as a certified auditor for the training course, a qualified sponsor must write a letter of
recommendation to attach with this form, describing the candidate’s interest in and dedication to the
field of poultry medicine. Qualified sponsors must not be related to the candidate but may be a
supervisor, colleague, former professor, or otherwise qualified individual within the field of poultry
veterinary medicine.
List relationship to candidate: _________________________________________________
I have known the candidate for ___ years.
I certify that I have attached to this application a letter of recommendation.  Yes  No
Name of Sponsor: ___________________________________________________
Signature of Sponsor: ________________________________________________
Date: _____________________________________________________________

CERTIFICATION OF APPLICANT
I DO HEREBY CERTIFY THAT ALL STATEMENTS MADE BY ME IN THIS APPLICATION ARE TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF; FURTHER, I UNDERSTAND
THAT IN THE EVENT I HAVE KNOWINGLY AND WILLFULLY MADE ANY FALSE STATEMENTS, I WILL BE
LIABLE FOR PUNISHMENT IN ACCORDANCE WITH ALL APPLICABLE LAWS AND STATUTES. FURTHER, I
PLEDGE TO ABIDE BY ALL THE CODES SET FORTH BY EACH COMPANY AND AGREE TO HONOR THE CODE
OF CONFIDENTIALITY. I ALSO UNDERSTAND THAT APPROVAL OF THIS APPLICATION WILL ALLOW MY
ENROLLMENT IN THE AUDITOR TRAINING COURSE; HOWEVER, I WILL STILL NEED TO SUCCESSFULLY
ATTEND AND PASS THE COURSE EXAMINATION TO BECOME A CERTIFIED AUDITOR. ADDITIONALLY, I
UNDERSTAND THAT, IF SUCCESSFUL, I WILL NEED TO ENROLL IN CONTINUING EDUCATION EVERY 4
YEARS THEREAFTER.
Signature: _______________________________
Date: ___________________________________
Application
A complete application must be sent to:
The National Poultry
Improvement Plan
1506 Klondike Road,
Suite 101
USDA-APHIS-VS
Conyers, GA 30094
Denise.L.Brinson@aphis.usda.gov with
cc to Elena.L.Behnke@aphis.usda.gov

For Department Use Only
Date
Received:

Reviewer:

Approval Granted for Candidate to Attend Workshop: 
Approval Denied for Candidate to Attend Workshop:



Anticipated Date of Next Workshop: __________________________________
Signature:
If Denied, List Reasons: