Paperwork Reduction Act 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 0579-0490. 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. |
0579-0490 Approved Exp. XX/XXXX |
Horse Protection Inspector (HPI) Application Template
Introduction paragraph/instructions
APPLICANT INFORMATION
First name
______________________ MI _____ Last Name________________________
Address 1: ________________________________________________________________
Address 2: ________________________________________________________________
City: _______, State: (state dropdown) Zip: _(number field)________
Phone: __________________________ Email: _____________________________
How did you hear about this position? ___________________________________________
QUALIFICATIONS
Tier 1 Qualifications (*must be met for USDA to evaluate the application*)
Are you a veterinarian? ○Yes ○No
IF NO – If you are not a veterinarian, are you a Veterinary Technician or otherwise employed by State or local government agencies to enforce laws/regulations pertaining to animal welfare (ie: Animal Control Officer, Animal Welfare Officer, etc)? ○Yes ○No
If yes, what is
your Official Title?
______________________________________________________
Ex:
If your title is Veterinary Technician, please specify if you are a
Registered Veterinary Technician, Certified Veterinary Technician,
Licensed Veterinary Technician, Specialized, etc.
If No, please provide an explanation: ___________________________________________________
Note: Veterinary Technicians will need to submit academic transcripts with this application.
Note: If you are a Veterinary Technician, you will need to submit your academic transcripts with this application.
IF YES to Veterinarian
Are you
currently licensed to practice veterinary medicine? Yes/No
Which
State, are you licensed to practice: State Dropdown (can select
multiple states)
License
number(s)_______________________________________________________________
Note: You will need to submit your academic transcripts with this application.
EMPLOYER INFORMATION
Name of Current Employer: ________________________________________________________
Employer Address: _______________________________________________________________
Employer Phone Number: _________________________________________________________
Name of Immediate Supervisor: ____________________________________________________
Phone Number of Immediate Supervisor: ____________________________________________
Do you grant permission for your supervisor to be contacted to verify Title and Employment status? ○Yes ○No
Tier 2 Qualifications
Comment Box
Please state, if any, prior experience working with the Horse Protection Act or enforcing the Horse Protection Act and its regulations.
Comment Box
Have you ever been found to have violated any provision of the Horse Protection Act or its regulations?
IF YES = Show Comments Box for explanation
IF YES = Show Comments Box for explanation
IF YES = Show Comments Box for explanation
Horse
Protection Inspectors must not have acted in a manner that calls into
question the applicant’s honesty, professional integrity,
reputation, practices, and reliability. As an HPI applicant, do you
authorize APHIS to obtain and review:
Criminal conviction records, if any. _______ (e-initials)
Official records of applicant’s actions while participating in Federal, State, or local veterinary programs, including veterinary board complaints, if any. ________ (e-initials)
Judicial determinations in any type of litigation, if any. _______ (e-initials)
I certify that the information provided herein is true and correct to the best of my knowledge. I certify that I am 18 years of age or older. I understand that my application for authorization as a Horse Protection Inspector may be denied for any of the reasons outlined in §11.19(a). I also understand that prior to authorization, I must successfully complete a formal HPI training program administered by APHIS and that authorization may be permanently disqualified if I am found to have failed to inspect horses in accordance with the procedures prescribed by APHIS or otherwise failed to perform the duties necessary for APHIS to enforce the Horse Protection Act and regulations.
e-SIGNATURE
____________________________________________________________
Printed Name
__________________________________________________________ _________________
ATTACHMENTS = Required if Veterinarian or Veterinary Technician
Submit Button = horseprotection@usda.gov
Example
submission note to applicant.
“Thank you for your
application. We will review and get back to you. If you have any
questions, please contact us at horseprotection@usda.gov”
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Carlson, Melissa - MRP-APHIS |
File Modified | 0000-00-00 |
File Created | 2024-07-20 |