Veterinary Student Externship Application
1. You will be asked to agree to the rules and regulations listed in our "Memorandum of Understanding," including details about our Payback Pledge. Please make sure you read this document before starting your application:

2. We will also ask you details about your extern coordinator, so please ensure you know who this is, and their phone number and email, before starting.

Contact Information
First Name *
Your answer
Last Name *
Your answer
Home Street Address *
i.e. Not school address
Your answer
City *
Your answer
State/Province *
Canadian Provinces are located at the bottom of the list. Choose "N/A" (also at the bottom of the list) if your address is not USA/Canada-based.
Zip Code *
e.g. 28806
Your answer
Country *
e.g. USA or Canada
Phone Number *
Please write as: 828-252-2079
Your answer
Email *
Please tell us your personal (i.e., not college) account
Your answer
Personal Details
Gender *
Date of Birth *
e.g. 10/24/1982
Your answer
Ethnicity *
We’d like to see if there are any under-represented applicants to our programs, so that we can think about ways to encourage them to join us. If you’d rather not respond, simply choose “Rather not respond.”
Never submit passwords through Google Forms.
This form was created inside of Humane Alliance of WNC, Inc.. Report Abuse - Terms of Service - Additional Terms