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Contact Information
Name
*
First Name
Last Name
Are you a licensed veterinarian?
*
select one
Yes
No
Yes, but I do not hold an active license
If you are a Veterinarian, please indicate the state(s) in which you are currently licensed to practice.
Do you hold an active DEA license?
select one
Yes
No
Yes, I do but but it is not currently active
What is your DEA license number?
Are you a licensed technician?
*
select one
Yes
No
Yes, but I do not hold an active license
Occupation and Position Title
Email
*
Verify Email
*
Phone
Address
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Languages Spoken
Have you volunteered on campaign with AB in the past either domestic or international?
*
Yes - domestic
Yes - international
Yes - both domestic and international
No
Which Animal Balance Program are you interested in participating in?
*
VETAID // GALáPAGOS ISLANDS
VETAID // ARIZONA
VETAID // CALIFORNIA
VETAID // LOUISIANA
VETAID // NEW MEXICO
VETAID // TENNESSEE
VETAID // TEXAS
Preferred Campaign Availability
*
In addition to your chosen campaign site, please let us know what your dates of availability are.
Are you fully vaccinated against COVID-19?
*
Yes
No
Partially - please explain in notes
I'm not fully vaccinated but...
Are you over 18 years of age?
*
Yes
No
Are you over 21 years of age?
*
Yes
No
Date Of Birth
(mm/dd/yyyy)
Health and Physical Fitness
Do you suffer from any illness, including but not limited to asthma, epilepsy, diabetes, allergies? Do you take any prescription drugs or over-the-counter medicines? Have you had any psychological / psychiatric illness in the last three years? If yes to any of the above, please supply more info in the box. If no, Enter N/A. *
Do you have health insurance?
Yes
No
Do you have any dietary restrictions?
Yes
No
If you chose YES please explain here.
Please Tell Us About You
*
Please list some of your interests, previous travel / volunteering experience, language skills, first aid, and any other relevant information or qualifications which might be useful.
Please provide names and contact information for your references (3):
*
How did you hear about us?
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