Application Part 3 Application Part 3

NIFA Veterinary Medicine

Loan Repayment Program (VMLRP)

APPLICATION PART 3: RECOMMENDATION

National Institute of Food and Agriculture US Department of Agriculture

OMB No. 0524-0050

Form Approved For Use Through XX/XX/XXXX

Purpose: This form is to be completed by each recommender for the applicant to the VMLRP listed in Section 2.

Instructions: Complete the sections below. Email this form to vmlrp.applications@usda.gov or fax to (833) 208- 8205 according to the instructions detailed in the Notice of Funding Opportunity (NOFO) prior to the deadline. The NOFO also includes criteria that will be used to evaluate the applicant and recommendations. For additional information, visit the VMLRP website (https://www.nifa.usda.gov/grants/programs/veterinary-medicine-loan-repayment-program).

Utilize this form to complete your response. Handwritten responses and attachments will not be accepted. Retain a copy in the event delivery failure requires resubmission of this form. A confirmation email from NIFA will be sent once the recommendation is processed.

Section 1. Applicant Information

Applicant’s Name:

First Name Middle Name Last Name Suffix

Relationship to Applicant:

How long have you known

the applicant?

(include approximate dates)

(Please limit your response to 50 characters)

Section 2. Recommender Information

Recommender’s Name:

First Name Middle Name Last Name Suffix

Position/Title: Organization/Business:

Work Address:

Street

City State Zip Code+4

Telephone Number:

(Area code required)

Email Address:

Section 3. Recommendation Instructions: All fields on this form are required. You may elect to cut and paste text from another document into the text fields. If you have no information to respond to a question, please indicate “No Comment” or

“N/A”.

Select the rating that best indicates your assessment of the applicant in relation to their peers.

Rating of Applicant	Exceptional	Outstanding	Average	Below Average	Poor	Don’t Know
Previous training and experience to serve in the veterinary shortage situation applied for.
Career goals and plans to achieve these goals.
Commitment to providing veterinary services needed to mitigate this shortage.
Critical thinking/Problem solving skills
Civic mindedness
Interpersonal skills
Potential for the applicant to succeed at the practice objectives in their application.
Overall assessment of applicant.

Short Answers: Please limit your response to 400 words for each question.

1. Provide an overall assessment of the applicant based on the ratings indicated above.

2. What are the applicant’s main strengths and weaknesses relative to veterinarian shortage situation area (a copy of this should be supplied by the applicant)?

3. What is your assessment of the applicant’s practice plans and likelihood of success relative to the specific shortage situation?

4. What is your overall recommendation of the applicant?

Section 4. Certification of Recommendation

I certify that the statements herein are true, accurate, and complete.

Signature of Recommender ^Date

Public reporting for collection of information is estimated to average 60 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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