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 0579-0353. The time
required to complete this information collection is estimated to average 20 minutes 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.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
VETERINARY SERVICES
1. COURSE TITLE:

3. PARTICIPANT’S NAME (Dr., Mr. Ms., Mrs.):

4. MAILING ADDRESS (Street, City, State, Zip Code, and Country):

5. WORK PHONE NUMBER:

6. WORK FAX NUMBER:

7. CELL PHONE NUMBER (Government or Business):

8. WORK EMAIL ADDRESS:

9. CHECK ONE:

STATE EMPLOYEE

OTHER

10. AGENCY/ORGANIZATION:

11. JOB TITLE:

12. PARTICIPANT’S OFFICIAL DUTY STATION:

APPROVAL SECTION

13. SUPERVISOR’S NAME:

14. SUPERVISIOR’S EMAIL ADDRESS:

15. SUPERVISOR’S APPROVAL:

16. APHIS OFFICIAL’S APPROVAL:

EMAIL THE COMPLETED NOMINATION FORM:
APHIS.VS.TRAINING@USDA.GOV.
A LIST OF THE VS TRAINING IS AT:
https://www.aphis.usda.gov/aphis/ourfocus/animalhealth/training-and-development

VS FORM 1-5
NOV 2021

0579-0353
EXP 03/2022

NOMINATION REQUEST FORM –
ANIMAL DISEASE TRAINING
2. DATE OF COURSE:

FEDERAL EMPLOYEE

OMB Approved