APPLICATION FORM

Name
Address
Course
Country
Tel No
Fax No
E-Mail
Course Dates for 2008
Name of Veterinary School
Study year in Veterinary School:
Person to contact in case of emergency:
Address
Phone Number
Are you a Vegetarian?
Food or medication allergies
NOTE: Do not travel without an epinephrine pen/kit and other appropriate allergy medicines if you have known potentially anaphylactic type allergies such as insect stings. I hereby declare that the information above is accurate and valid I hereby declare that I have read the admission requirements for this program and that Wildlifevets.com reserves the right to refuse access to the lodge and practice based on inadequate payment or inappropriate behavior. I hereby declare that I have an above average level of physical and mental fitness required to complete the program. Documents required: Curriculum vitae Motivation letter Reference letter (internship) Proof of elective module (externship)