Lincoln Memorial University
School of Allied Health Sciences
Veterinary Medical Technology Program
Application for Admission
Associate of Science
Name
Last
First
Middle
Preferred Name
E-Mail
Suffix
(e.g. name@net.com)
Preferred Method of Contact
Permanent Mailing Address
Address Line 1
State
Address Line 2
City
Zip
Parish or County
Country (if not USA)
Day Telephone
Night Telephone
Cell Phone
Date of Birth
Age Today
Gender
Ethnicity / Race (Optional)- circle one
White
Black
Hispanic
Asian
Other_____________________
Place of Birth
City
Are you a U.S. citizen?
State
since
Immigration Status (if applicable)
Permanent Resident
Alien Registration Number
VISA Type
Phone
State of Legal Residence
Country (if not USA)
If no, what is the country of your citizenship?
U.S. State of Residence
Parent/Guardian
Father is
living
Name
Address
Parish or County of Birth
Refugee
deceased
Non-Immigrant
issued in
Mother is
Name
Address
living
on
deceased
Phone
State of Legal Residence
No student may be admitted as a Tennessee resident unless all residence requirements are fulfilled and verified by the Office of the Registrar,
Lincoln Memorial University.
High School and Colleges Attended/Dates of Attendance
Name
From
To
Name
From
To
Name
From
To
Name
From
To
Animal Experience
List hours below. (AS applicants must have 20 hours of clinical observation)
1.
Experience
City
Reference
Reference’s Telephone Number
Dates From
To
Total Hours
State
Volunteered
Paid
Description of Responsibilities:
2.
Experience
City
Reference
Reference’s Telephone Number
Dates From
To
Total Hours
State
Volunteered
Paid
Description of Responsibilities:
Other Employment Experience
1.
Type of experience
City
Reference
Reference’s Telephone Number
Dates From
To
Total Hours
Description of Responsibilities:
Page 2 of 5
State
2.
Type of experience
City
Reference
Reference’s Telephone Number
Dates From
To
State
Total Hours
Description of Responsibilities:
3.
Type of Experience
City
Reference
Reference’s Telephone Number
Dates From
To
State
Total Hours
Description of Responsibilities:
Extracurricular and Community Activities (list the three you consider the most significant)
Type of Activity
Dates From
To
Dates From
To
Dates From
To
Description of Activity:
Type of Activity
Description of Activity:
Type of Activity
Description of Activity:
Page 3 of 5
Honors and Awards (list the three you consider the most significant)
Honor/Award
Date Received
Description of Honor/Award:
Honor/Award
Date Received
Description of Honor/Award:
Honor/Award
Date Received
Description of Honor/Award:
Personal Statement (attach to application)
Your personal statement should include but not be limited to your veterinary medical technology career. You should also address what you
consider your strongest character trait and how this trait has helped you and will continue to help you succeed while in college. This statement
should be one to two pages typed, doubled spaced, with size 12 font.
Confidential Evaluators (please list the names of the individuals who will submit evaluations on your behalf)
(evaluation forms are attached)
Academic evaluator
Veterinarian or credentialed technician evaluator
Were you ever the recipient of any action (e.g. dismissal, disqualification, suspension, etc.) by any school
for unacceptable academic performance or conduct violations?
Yes
No
If yes, provide a brief explanation.
Have you ever pled nolo contendere (no contest) or been convicted of either a felony or a misdemeanor,
other than a minor traffic violation?
Yes
No
If yes, provide a brief explanation.
Page 4 of 5
Note: Some states may require a background check and have other restrictions on credentialing. Admission into
the VMT program LMU in no way guarantees you will receive credentials from a particular state. Contact the
state veterinary boards for credentialing guidelines in the state of your choice.
Signature
With your signature, you verify that the information contained in this application is complete and accurate.
Date of Submission
At LMU, there is a rolling admissions policy. In order to be considered for admissions to the AS VMT
program, you will want to send your application in as early as possible. Acceptance of applications for
fall begins on January 1 of each year. A checklist is attached for all items that need to be submitted for
consideration. All new cohorts begin in the Fall semester each academic year.
FINAL ACCEPTANCE OF ADMISSION INTO THE VETERINARY MEDICAL TECHNOLOGY
PROGRAM IS CONTINGENT UPON ACCEPTANCE TO LINCOLN MEMORIAL UNIVERSITY.
You may hand deliver your application or it may be delivered via mail to:
Veterinary Medical Technology Program
Associate of Science
Lincoln Memorial University
6965 Cumberland Gap Parkway
Harrogate, TN 37752
For Departmental Use Only
Date Accepted/Denied Application Into Program:__________________________________________________
VMT Admissions Personnel: ________________
Page 5 of 5