Vet Tech Application & Information Veterinary Program Application Veterinary Technology Program Application Personal InformantionName* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Crowder Student ID NumberEmail* Phone Number*Alternate Phone Number College Education #1List high school or GED and colleges AttendedName of School*Address of School* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Start Date* MM slash DD slash YYYY End Date* MM slash DD slash YYYY Add a Second School Yes No College Education #2List high school or GED and colleges AttendedName of School*Address of School* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Start Date* MM slash DD slash YYYY End Date* MM slash DD slash YYYY Add a Third School Yes No College Education #3List high school or GED and colleges AttendedName of School*Address of School* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Start Date* MM slash DD slash YYYY End Date* MM slash DD slash YYYY Do you have college ready scores for:Have you completed Biology or Zoology with a minimum grade of a "C"?* Yes No Have you completed Biology 101?* Yes No Have you completed English 101?* Yes No English (are you at ENGL 101 or above)?* Yes No What level of math have you completed?What is your GPA?Occupational ExperienceList all employment within the past 5 years, start with the last date of employment (Employers may be contacted as references)Employer*Employer Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Type of Employment*Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Add a Second Employer Yes No Occupational ExperienceList all employment within the past 5 years, start with the last date of employment (Employers may be contacted as references)Employer*Employer Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Type of Employment*Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Add a Third Employer Yes No Occupational ExperienceList all employment within the past 5 years, start with the last date of employment (Employers may be contacted as references)Employer*Employer Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Type of Employment*Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Work Experience within Veterinary Medicine*list all animal related experience, and the number of years in each capacity (include experience with animal husbandry) ReferencesPlease list the names and complete mailing addresses of three persons (not relatives or friends) who can evaluate your aptitude for the veterinary technology profession. Recommendations should be from a practicing veterinarian, a college instructor, and another person of the applicant’s choice. (Employers who can speak to work ethic are often a good option.) Letters may be mailed directly to the Veterinary Technology Program Director prior to the application deadline, or may be submitted with the application.Reference #1* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneReference #2* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneReference #3* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Clinic Name and Location of Observation HoursNumber of Observation Hours CompletedOverall GPA Please complete the Proof of Shadowing form.Essay 1*Please write an essay of 250-500 words on the following subject: The Veterinary Nurse Initiative (VNI), which seeks to unite the veterinary technician profession under a single veterinary nurse title, standardize credentialing requirements and define scope of practice, continues to make progress despite some challenges. Detail your thoughts on this trend and describe any characteristics or experience which will set you apart from other candidates. Essay 2*Please write a 1/2 page essay on the following subject: From time to time, euthanasia is practiced in the field of veterinary medicine. Convey your thoughts about euthanasia. In your response, include whether or not you think that euthanasia should be practiced and why you have arrived at that conclusion. AcknowledgementsAcknowledgement 1*I do hereby certify that the above information is complete and correct to the best of my knowledge under penalty of perjury. Yes I Understand Acknowledgement 2*I understand that any question answered in a false manner will result in the application being void. Yes I Understand Acknowledgement 3*I understand that I will not be considered for admission into the Veterinary Technology Program until I have completed the application process as outlined in the application information sheet. Yes I Understand “The Family Educational Rights and Privacy Act of 1974”, Public Law 93-380 as amended and signed into law by President Ford on December 31, 1974, states that enrollees have the right to examine confidential files. It also states that they may waive this right if they do so desire. The law provides that references may be either confidential or non-confidential at the option of the registrant. The registrant has the option to inspect the references in a non-confidential file. Confidential references are those which the registrant has waived the right to see. Please consider the following in making a decision to have confidential or non-confidential references. 1. School officials prefer to see confidential references, believing the references are more frank in such credentials. The limited number of studies which have been made of confidential vs. non-confidential references Indicate a preference of both hiring officials and college faculty for confidential or enclosed references. 2. Registrants should be most selective in asking persons to write references for them. The persons selected should know the registrant well and be able to state facts and competencies of the registrant. 3. Writers of references will be informed at the time of writing that the reference is confidential or that the registrant will be permitted to see the reference. I Have Elected:* A Confidential File A Non-Confidential FIle By execution of the application, I do hereby authorize Crowder College or it’s representatives to verify all information contained within this application, and do waive any privilege I may have as to confidentiality to Crowder College or it’s representatives, and I do authorize any agency – – educational, health, or law enforcement – – to furnish to Crowder College or it’s representatives the information necessary to validate the information contained upon my veterinary technology application. Signature*Type in full name to sign and affirm this applicationDate Signed MM slash DD slash YYYY Thank you for your interest in Crowder’s Veterinary Technology Program. If you have any questions call 417-455-5590 or email sestep@crowder.eduPlease upload three Letters of Reference, Shadow Verification Form, and College Transcripts.First letter of Reference*Accepted file types: jpg, pdf, png, Max. file size: 50 MB.Second letter of Reference*Accepted file types: jpg, pdf, png, Max. file size: 50 MB.Third letter of Reference*Accepted file types: jpg, pdf, png, Max. file size: 50 MB.Shadow Verification form*Accepted file types: jpg, pdf, png, Max. file size: 50 MB.College Transcript*Accepted file types: jpg, pdf, png, Max. file size: 50 MB.PhoneThis field is for validation purposes and should be left unchanged. Applicant reference check. The applicant has chosen this to be a confidential reference. An honest and complete opinion will be most helpful. The applicant has chosen this to be a non-confidential reference. An honest and complete opinion will be most helpful. This reference form is associated with the following Crowder Veterinary Technician program applicant. If this is incorrect, please update the first and last name of the applicant here.* First Last How long have you known this individual and in what capacity?*From your experience with this individual please rate him/her in the following areas as they pertain to the practice of veterinary technology.Communication* Very strong evidence skill is present Strong evidence skill is present Some evidence skill is present Insufficient evidence for or against skill Strong evidence skill is not present Coping* Very strong evidence skill is present Strong evidence skill is present Some evidence skill is present Insufficient evidence for or against skill Strong evidence skill is not present Commitment to Task* Very strong evidence skill is present Strong evidence skill is present Some evidence skill is present Insufficient evidence for or against skill Strong evidence skill is not present Conflict Management* Very strong evidence skill is present Strong evidence skill is present Some evidence skill is present Insufficient evidence for or against skill Strong evidence skill is not present Problem-Solving* Very strong evidence skill is present Strong evidence skill is present Some evidence skill is present Insufficient evidence for or against skill Strong evidence skill is not present Organization and Planning* Very strong evidence skill is present Strong evidence skill is present Some evidence skill is present Insufficient evidence for or against skill Strong evidence skill is not present Grooming* Very strong evidence skill is present Strong evidence skill is present Some evidence skill is present Insufficient evidence for or against skill Strong evidence skill is not present Punctuality* Very strong evidence skill is present Strong evidence skill is present Some evidence skill is present Insufficient evidence for or against skill Strong evidence skill is not present Would you recommend this person for the Vet Tech program?* Yes No Additional CommentsDate* MM slash DD slash YYYY Name* First Last Phone Number*Email Address* TitleThis field is hidden when viewing the formHIDDEN – Applicant Email
