Application Part 1_Program_AIedits

NIFA Veterinary Medicine
Loan Repayment Program (VMLRP)

National Institute of Food and Agriculture
US Department of Agriculture
OMB No. 0524-0050
Form Approved For Use Through XX/XX/XXXX

APPLICATION PART 1: PROGRAM
Instructions: Complete the sections below. Email the form(s) packet to vmlrp.applications@usda.gov or fax to (833) 2088205 according to the instructions detailed in the Request for Application prior to the deadline. For additional
information to prepare your application documents, visit the VMLRP website
(https://www.nifa.usda.gov/grants/programs/veterinary-medicine-loan-repayment-program/vmlrp-generalinformation).

Section 1. Identifying Information
1. Application Type:

 NEW (individuals who is not a current or previous VMLRP
awardee)
 RENEWAL (individuals applying to continue serving the
original awarded shortage area)

2. Applicant’s Name:

First

Middle

Last

Suffix

3. Other Names Used:
(e.g. maiden name)

Check the VMLRP website for the code of the shortage area to which you are applying. The
Shortage Identification Code entered on this form MUST match the code entered on the Intent of
Employment form section 9. An applicant may apply to only ONE shortage situation.
4. Enter the fivecharacter Shortage
Identification Code:
5. Shortage Type (Mark
one box):

 Type I: Private Practice (minimum 80% time)
 Type II: Private Practice – Rural Area (minimum 30% time)
 Type III: Public Practice (minimum 49% time)

Section 2. Residential Contact Information
1. Residential
Address:

Street

City

2. Contact Number:

State

Zip Code+4

(Area code required)

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USDA is an equal opportunity lender, provider and employer.

3. Personal Email
Address:
Section 3. Employment Contact Information
1. Position Title:

2. Organization/Practice:

3. Division/School:

4. Department/Section:

5. Address:

Street

City

6. Telephone
Number:

State

Zip Code+4

Ext:

(Area code required)

7. Work Email
Address:
8. Please contact
me at:

Personal Phone

Work/School Phone

Section 4. Education, Training, and Licensure
Note: Include a maximum of a two-page Resumé. An additional page may be submitted to highlight
publications, patents, conference presentations, book chapters, etc. If Ph.D., attach a synopsis of your
dissertation abstract limited to approximately two double-spaced pages.
Pre-veterinary Medical Education:
1. Undergraduate
Degree (1):
Major/Field of
Specialization:

Year

Degree

Conferring
Institution:

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NIFA invests in and advances agricultural research, education, and extension and promotes transformative discoveries that solve societal challenges.
USDA is an equal opportunity lender, provider and employer.

2. Undergraduate
Degree (2) or
Graduate Degree:
Major/Field of
Specialization:

Year

Degree

Conferring
Institution:

3. Doctor of
Veterinary
Medicine:

Accredited by
AVMA*?

Yes
 No

(or Equivalent Degree)

Year:

___________________________________________________________________

Degree:

___________________________________________________________________

Conferring Institution: _________________________________________________________________
The Veterinary College where you obtained your DVM (or equivalent) must be accredited by the AVMA. Visit the AVMA
website for a full list of accredited schools: https://www.avma.org/education/center-for-veterinary-accreditation/accreditedveterinary-colleges.

Post Veterinary Medical Graduate or Specialty Training (Internship, Residency, PostDoctoral Appointments, etc.): Provide the area(s) in which you have post-DVM graduate or
specialty training and indicate whether you are board-eligible or -certified in that area.
4. Primary
Specialty:
Board Eligible: ☐ Yes
☐ No

Board Certified: ☐ Yes
☐ No

_______________
Date Certified

Certifying Board or College (If applicable)

5. Secondary
Specialty:
Board Eligible: ☐ Yes
☐ No

Board Certified: ☐ Yes
☐ No

_______________
Date Certified

Certifying Board or College (If applicable)

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NIFA invests in and advances agricultural research, education, and extension and promotes transformative discoveries that solve societal challenges.
USDA is an equal opportunity lender, provider and employer.

6. Graduate
Degree (1):

Year

Degree

Major/Field of
Specialization:
Conferring
Institution:

7. Graduate
Degree (2):

Year

Degree

Major/Field of
Specialization:
Conferring
Institution:

8. Internship:

9. Residency:

Yes
 No

Program Name

Start Date

Completion Date

Institution/Location

Yes
 No

Program Name

Start Date

Institution/Location

10. Current
Veterinary
License(s):

 Yes*
 No
 Pending
 N/A

State

Expiration Date

State

Expiration Date

State

Expiration Date

State

Expiration Date

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NIFA invests in and advances agricultural research, education, and extension and promotes transformative discoveries that solve societal challenges.
USDA is an equal opportunity lender, provider and employer.

Completion
Date

11. USDA APHIS
Accreditation:






Yes*
No
Pending
N/A
Accreditation Expiration Date

*If you answered “Yes” attach a PDF copy of current veterinary license(s) and/or USDA APHIS Accreditation.

Other Relevant Training

12. In the space below, list any other relevant training programs, courses of study, licensures, or
professional certifications (requiring greater than 8 hours of direct applicant participation). Be
sure to include the name of program and a brief description/synopsis, including date completed,
date of expiration (if applicable), and credential earned (if applicable) (600-character limit):

Section 5. Service Obligation
Note: If you have a service obligation, you may still be eligible for VMLRP consideration if your service
obligation has been or can be deferred for the entire period of your VMLRP contract. For assistance,
please contact VMLRP staff at vmlrp.applications@usda.gov.
1.

Do you owe a
service payback
obligation?

2.

Program Name:

3.

When do you expect to
fulfill your obligations?

 Yes (Continue with questions


below)
No (Skip to Section 6)

Month

Day

Year

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NIFA invests in and advances agricultural research, education, and extension and promotes transformative discoveries that solve societal challenges.
USDA is an equal opportunity lender, provider and employer.

Section 6. Voluntary Disclosures
Completion of items in this section is VOLUNTARY. The information provided will be used to measure
the extent to which members of these groups are applying for and/or receiving VMLRP contracts and/or
for program evaluation. Declining to answer these questions will not affect your application.
1.

How did you learn about
the VMLRP?

3.

Gender:
(Select one)

 Female 

Ethnicity:
(Select one)

 Hispanic or Latino

4.

2.

Birth Year:

Male

 I do not

wish to disclose

 Not Hispanic or Latino

 Other_______
A person of Mexican, Puerto Rican,
Cuban, South or Central American,
or other Spanish cultures or origins,
regardless of race.

 I do not wish to disclose
5.

Race:
(Select one or more)

 American Indian or Alaska Native

A person having origins in any of the
original peoples of North or South
America (including Central America),
and who maintains tribal affiliation or
community attachment.

 Asian

A person having origins in any of the
original peoples of the Far East,
Southeast Asia, or the Indian
subcontinent, including, for example,
Cambodia, China, India, Japan, Korea,
Malaysia, Pakistan, the Philippine
Islands, Thailand, and Vietnam.

 Black or African American

A person having origins in any of the
black racial groups of Africa. Terms
such as “Haitian” or “Negro” can be
used in addition to “Black or African
American.”

 Native Hawaiian or

A person having origins in any of the
original peoples of Hawaii, Guam,
Samoa, or other Pacific Islands.

 Hispanic or Latino

A person of Cuban, Mexican, Puerto
Rican, South or Central American, or
other Spanish culture or origin,
regardless of race. The term,
“Spanish origin,” can be used in
addition to “Hispanic or Latino.”

Other Pacific Islander

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NIFA invests in and advances agricultural research, education, and extension and promotes transformative discoveries that solve societal challenges.
USDA is an equal opportunity lender, provider and employer.

 White

A person having origins in any of the
original peoples of Europe, the
Middle East, or North Africa.

 Other
 I do not wish to disclose.
6.

A person is disabled if he or she has a physical or mental impairment which substantially limits one or more
major life activities, has a record of such impairment, or is regarded as having such impairment.
Disability:
(Check all that apply)

 Yes
 No
 I do not wish to disclose.

Section 7. Certifications
1. Certification of Non-delinquent Status
The Federal Debt Collection Procedures Act of 1999 precludes a debtor who has a federal
judgment lien against his/her property arising from a federal debt from receiving federal funds
until the judgment is paid in full or otherwise satisfied. As the applicant, I certify to the best of
my knowledge and belief;
I hereby certify that I



do



do not

I am not presently debarred, suspended, declared ineligible, or voluntarily
excluded from covered transactions by any Federal department or agency;

I hereby certify that I



do



do not

I have not within a three year period preceding this application been
convicted or had a civil judgment rendered against me for commission of
fraud or a criminal offense in connection with obtaining, attempting to
obtain, or performing a public (Federal, state, or local) transaction or
contract under a public transition; or commission of embezzlement, theft,
forgery, bribery, falsification, or destruction of records, making false
statement, or receiving stolen property;

I hereby certify that I



do



do not

have a judgment lien against my property arising from a debt to the United
States

I hereby certify that I



am



am not

delinquent on any debt to the United States

2. Certification of Accuracy of Information Provided

 I certify 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 the
information given may be investigated and any false representation is sufficient cause for
rejection of the application, or, if awarded loan repayment, that I am liable for return of

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NIFA invests in and advances agricultural research, education, and extension and promotes transformative discoveries that solve societal challenges.
USDA is an equal opportunity lender, provider and employer.

all awarded funds and, further, that any false statement may be punished as a felony
under U.S. Code, Title 18, Section 1001. I am aware 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 to other authorized Government officials.
3. Release to Contact Recommenders

 I certify that I am requesting recommendation(s) from individual(s) of my choosing that

will be included in my Veterinary Medicine Loan Repayment Program (VMLRP) application.
My application, including the completed recommendation forms submitted by my
recommenders, will be used by USDA officials to determine my eligibility for participation in
the VMLRP. I understand that the recommendations I am requesting shall be held in
confidence and protected from disclosure by officials of the VMLRP according to Privacy Act
System of Records (see Confidentiality and Privacy Act Notice). I authorize administrators of
the VMLRP and other authorized Government officials to contact the individual(s) I have
identified to request any additional information that may be needed in determining my
eligibility for participation in the VMLRP.
4. Voluntary Waiver of Future Rights to Access Confidential Recommendations

 I understand that I will not have access to the recommendations based on the statement of
confidentiality contained in the “Release to Contact Recommenders” section above.

Signature of Applicant (certified electronic or scanned ink)

Date

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NIFA invests in and advances agricultural research, education, and extension and promotes transformative discoveries that solve societal challenges.
USDA is an equal opportunity lender, provider and employer.

Section 8: Intent of Employment
Instructions: Complete Section 9 with contact information for the hiring official who can provide verification of intent to
offer you employment, including the time and resources for you to conduct your proposed service, in a veterinarian
shortage situation. Section 10 must be completed by the hiring official identified in Section 9. This intent to offer is not
legally binding but should represent a good faith expectation that the probability of employment is high. If you are selfemployed or intending to start your own practice, you may list yourself as the hiring official in Section 9 and complete
Section 10.

Section 9: Employment Contact Information

Note: The applicant must obtain information needed to complete this section from the appropriate authorized hiring
official for the practice or organization. If you are, or expect to be, the owner of the practice you will be working at, then
you will be the hiring official for the purposes of the contact information requested below.
1.

Applicant
Name:
I am currently the owner/hiring official of the practice.
I intend to establish a new practice that I will own.
I am employed by a public entity or a private practice.
I intend to be employed by a public entity or a private practice.

Note: Check the VMLRP website for the code of the shortage area to which you are applying. The code
entered on this form MUST match the Shortage Identification Code entered on page one of this
application.
Enter the five-character Shortage Identification Code:

2.

Contact Information for the Prospective Employer/Hiring Official

Practice/Organization:
Address:
Name of Hiring Official:
Email Address:
Telephone Number(s):

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NIFA invests in and advances agricultural research, education, and extension and promotes transformative discoveries that solve societal challenges.
USDA is an equal opportunity lender, provider and employer.

Section 10. Certification of Employment

Note: This section is to be completed by the hiring official identified in Section 9.
I certify that the applicant identified above will be provided the necessary time and resources to perform qualified
veterinary services, in accordance with the terms and conditions of his/her agreement with the Secretary of Agriculture, for
the practice/organization identified in Section 9 for a minimum of three years from the date a VMLRP contract is initiated,
assuming satisfactory performance of duties by the applicant. I further certify that the information provided on this form is
accurate to the best of my knowledge. I am aware that any false, fictitious, or fraudulent statements or claims may subject
me to criminal, civil, or administrative penalties.
Signature of Hiring Official (certified electronic or scanned ink)

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 data 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, OGFM, 2312 East Bannister Road, Mail Stop 10,000, Kansas City, MO 64131, Attention
Policy Section. Do not return the completed form to this address.
OMB No. 0524-0050
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NIFA invests in and advances agricultural research, education, and extension and promotes transformative discoveries that solve societal challenges.
USDA is an equal opportunity lender, provider and employer.