Review Your Information First Name * Middle Name Last Name * Maiden/Former Last Name * Residence is outside the United States YesNo Please enter at least one phone number: Cell Phone Number * [mask* cell-number "___-___-____"] Home Phone Number [mask home-number "___-___-____"] Email Address * Birthdate * [mask* your-birthdate "__-__-____"] Gender * —Please choose an option—MaleFemale GENERAL INFORMATION - CONTINUED Street Address * Apartment/PO Box City * State/Location * —Please choose an option—ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYPuerto RicoOther Zip Code * DESIRED PROGRAM START DATES Select Your 1st Choice * June 29, 2020September 28, 2020January 4, 2021April 5, 2021 Select Your 2nd Choice * June 29, 2020September 28, 2020January 4, 2021April 5, 2021 Are you a citizen of the United States? * YesNo Veteran, military spouse, or child of service member applying for Veterans benefits? * YesNo HIGH SCHOOL EDUCATION High school graduates, individuals with a State Authorized School Equivalency Certificate/Diploma, or students currently pursuing a high school diploma or equivalency certificate/diploma may apply for admission to Bel-Rea. Bel-Rea accepts diplomas/certificates from accredited high school or equivalency programs, or rigorous home school programs. Documents produced by diploma mills will not be approved. Please select one of the following: Public or private U.S. high schoolLegitimate home school high school programForeign high schoolGED, TASK, or HISET (State Authorized High School Equivalency Certificate/Diploma) Name of High School * Location of High School (City, State) * Country * Date of Graduation (or anticipated) * [mask* high-school-graduation-date "__-__-____"] AP Exams Select category below for completed or anticipated AP Exams (score of 3 or higher, supporting class required): * Public or private U.S. high schoolLegitimate home school high school programForeign high schoolGED, TASK, or HISET (State Authorized High School Equivalency Certificate/Diploma) If, GED, TASC or HISET please fill out the following GET, TASC, or HISET Test Site: GET, TASC, or HISET Date: [mask ged-date "__-__-____"] COLLEGE EDUCATION Have you attended college? * YesNo If yes, please select a category below for completed or current college courses (grade of "C" or higher and 3 or more semester/ quarter credit hours required): Select a category: * ChemistryHumanitiesMathPerspectivesTechnical WritingOther Please enter all colleges attended (most recent first) Name of College #1 Year(s) Attended: From: To: Major or Main Coursework Focus Degree Earned (if applicable) Graduation Date (if applicable) [mask college-1-graduation-date "__-__-____"] --- Name of College #2 Year(s) Attended: From: To: Major or Main Coursework Focus Degree Earned (if applicable) Graduation Date (if applicable) [mask college-2-graduation-date "__-__-____"] --- Name of College #3 Year(s) Attended: From: To: Major or Main Coursework Focus Degree Earned (if applicable) Graduation Date (if applicable) [mask college-3-graduation-date "__-__-____"] VETERINARY MEDICAL EDUCATION Have you attended another AVMA-accredited veterinary technology * YesNo If yes, which one(s)? Have you completed a NAVTA-approved veterinary assistant certification program? * YesNo If yes, please explain MILITARY COURSEWORK Have you attended any military classes? * YesNo If yes, please select a category below for completed or current college courses (grade of "C" or higher and 3 or more semester/ quarter credit hours required): Select a category: * ChemistryHumanitiesMathPerspectivesTechnical WritingOther ADDITIONAL MILITARY INFORMATION Branch of Military Military Coursework Year(s) Attended: From: To: Major or Main Coursework Focus Degree Earned (if applicable) Graduation Date (if applicable) [mask military-graduation-date "__-__-____"] EMPLOYMENT Please provide a brief summary of your current and previous employment and volunteer work. WHERE DID YOU HEAR ABOUT BEL-REA? Select a source: * Social MediaEventTelevisionRadioFormer/Current Student or GraduateEmployerVeterinary ReferralOther If applicable, please provide the name of the referral source (i.e. - Facebook, Employer or Veterinary Clinic's Name, etc.): [multistep "10-10-/thank-you/"]