Instructions for VS Form 1-36A |
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Block 1: Name of Veterinarian
Enter full name as used professionally.
Block 2: Social Security Number
Enter your last 4 digits of your social security number. (Read the Privacy
Act Notice on the back of the form)
Block 3: Birthday
Enter the 2 digit month, day and year (mm/dd/yyyy).
Block 4: Name of College (Graduated)
Enter the name of the veterinary school or college you graduated from.
Block 5: Year Graduated
Enter the year of graduation.
Block 6: Date of Orientation
Enter complete date orientation was attended (mm/dd/yyyy).
Block 7: State of Orientation
Enter the State where orientation was attended.
Block 8: Home Mailing Address
Enter your complete home mailing address.
Block 9: County
Enter the county your home address is located.
Block 10: Home Telephone Number
Enter your home telephone number.
Block 11: Home Fax Number
Enter fax number if available.
Block 12: Business Name
Enter name of practice/business.
Block 13: Business Address
Enter the complete address of your veterinary practice.
Block 14: County
Enter the name of the county your veterinary practice in located.
Block 15: Business Telephone Number
Enter the area code and telephone number of your veterinary practice.
Block 16: Business Fax Number
Enter your business fax number.
Block 17: Cell Number
Enter your cell phone number.
Block 18: E-mail Address
Enter e-mail address if available. (This e-mail address should be a unique
address and not a shared company address.)
Block 19: Employer Type
Enter your employer type, i.e., Private, State.
Block 20: Professional Activity
Enter the type of business you work in—large animal, mixed, laboratory,
etc.
Block 21: Species Specialty
Enter your specialty if applicable (swine, bovine, etc.).
Block 22: State Applying for Accreditation
Enter State where you are applying to perform accredited work
Block 23: State License Number
Enter your State license number.
Block 24: Do you want your name and business
information released for a public search of accredited veterinarians?
Check either yes or no. Yes will allow the public to access your business information
Tasks for Accredited Veterinarians and Certification:
Read the tasks, the Standards for Accredited Veterinarian Duties (9CFR
161.3), and the certification statement before signing and dating the application.
By your signature you are certifying that you can perform the tasks for accredited
veterinarians, and that you have read the "Standards" and agree to
conduct all accredited veterinarian activities in accordance with the Standards
for Accredited Veterinarian Duties.
Block 25: Signature of Veterinarian
Applicant must sign in his or her own hand.
Block 26: Date of Signature
Enter the date that you signed the application.
Block 27-30
Completed by Federal and State officials.
Note: The VS Form 1-36A (PDF 1.05MB) Application for Veterinary Accreditation is covered by the Privacy Act Notice printed on the reverse side. The application will not be accepted unless the Privacy Act Notice is attached to the application or printed on the reverse side.
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