MIDDLESEX COMMUNITY COLLEGE
Veterinary Assistant Emergency and Specialty Center Internship
Please provide a copy of Veterinary Assistant Certificate with application
APPLICANT’S LEGAL NAME (Last) (First) (Middle)
BIRTH DATE (Month/Day/Year)
GENDER (Check One)
□ Male □ Female
ADDRESS (No. and Street) (Apt. #) (City or Town) (State) (Zip Code)
HOME TELEPHONE (Area Code)
Are you a United States Citizen?
□ Yes □ No □ Permanent Resident
ETHNICITY/RACE
Please provide the following ethnicity and race data. This information is
requested on a voluntary basis by the U.S. Department of Education,
National Center for Education Statistics. Your answers will not affect
admission to or registration in the college.
Do you consider
yourself to be
Hispanic/Latino?
□ Yes
□ No
What is your race? select one or more:
□ White (10) □ Black or African
American (20)
□ American Indian or Alaskan Native (50)
□ Native Hawaiian or Other Pacific
Islander (80)
□ Asian (45) □ Other (90)
Is English your Second Language?
□ Yes
□ No
Students with a criminal background will be denied access into this program.
Are you willing to submit information for a criminal background check?
□ Yes
□ No
Have you been convicted of a felony? □ Yes □ No
Military Status
□ Are you currently on active duty with the U.S. Armed Forces?
□ Are you currently a member of the National Guard or Reserve?
□ Have you ever served in the U.S. Armed Forces?
□ Are you a dependent member of the U.S. Armed Forces?
Are you a High School Graduate? □ Yes □ No Year:
Are you currently Attending High School? □ Yes □ No
GED certification: □ Yes □ No
Major/ Area of
Concentration
Copy of Veterinary Assistant Certificate
