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/"]