Po Box 1100, 1176 Seven Springs Rd. / Raymond, Mississippi 39154-1100

APPLICATION FOR SELECTION TO VETERINARY TECHNOLOGY

HINDS COMMUNITY COLLEGE

PO BOX 1100, 1176 SEVEN SPRINGS RD. / RAYMOND, MISSISSIPPI 39154-1100

601-857-3334 OR 601-857-3456

Instructions:

1. Complete this form and email to: HCC Veterinary Technology Department:

2. Request the registrar of your high school or any colleges that you have attended to forward an Official Transcript from that institution to the Hinds Community College Office of Admissions Records AND also to the Veterinary Technology Department.

Personal Data:

Name: ______

(If you have attended Hinds before or currently attending please give student ID# and/or the name that your Hinds course work would be listed as: ______)

Address: ______

City: ______, State: ______Zip: ______

Your contact telephone number ______

Email address: ______

Educational Data:

List high school and colleges that you have attended

Name of School/City & StateDid you graduateDates Attended

______[ ] Yes [ ] No____ to ____

______[ ] Yes [ ] No____ to ____

______[ ] Yes [ ] No____ to ____

______[ ] Yes [ ] No____ to ____

Individual Student Data:

The following information is needed for licensure requirements.

Have you ever been convicted of a misdemeanor or felony?[ ] Yes [ ] No

If yes, explain: ______

______

Please refer to college handbook for drug test policy.

Additional Information:

Have you applied for or have been a student in the Veterinary Technology program prior to this date?

[ ] Yes [ ] No

If so when did you apply and/ or attend? ______

How many semestersdid you complete while in the program? ______

I certify that the above statements in this application are true and complete to the best of my knowledge. I am aware that falsificationof this application is a basis for denying admission or for immediate termination of enrollment.

Signature: ______Date: ______

Please see the Veterinary Technology Webpage for more information, dates, and other requirements to be met before your interview date. A minimum of 25 hours of observation work must be completed prior to your interview and your Observation Form(s) must be returned prior to your interview. We will not accept Observation forms during your interview.

All correspondence for interviews and selection into this program will be sent to the email address that you have provided. Please make sure that you have provided a valid email address.

Hinds Community College offers equal education and employment opportunities and does not discriminate on the basis of race, color, national origin, religion, sex, age, disability or veteran status in its programs and activities. The following person has been designated to handle inquiries regarding the non-discrimination policies: Dr. Debra Mays-Jackson, Vice President for the Utica and Vicksburg-Warren Campuses and Administrative Services, 34175 Hwy. 18, Utica, MS 39175: 601.885.7002

______

For office use only: Date Application Received:______

Date of Interview: ______

Notification Contact: ______