All information is considered confidential and will become part of your student file at Smartk9 Academy, LLC. It is very important to your future that you provide accurate answers to each question asked. If you need more room to answer any question, use another sheet of blank paper for your remarks. Remember, the more complete information you provide, the faster the Admissions person can take action on your Application.

Name:________________________________________________________

Address:_____________________________________________________

city____________________ State_____________ zip______________

Phone numbers:

Home: __________________Work: _________________Cellular: ____________________

Date of Birth:________________Birthplace:_______________

Sex:___________

Mailing Address__________________________________________

city_____________________ state____________zip____________

Social Security number______________________ Driver’s License number______________________

References: Name, address, Telephone number and relationship for three.

1. Name_____________________________________________________________

Relationship_____________________________

Address________________________________City_______________State________

Zip______________

Home phone______________________work phone___________________

2. Name_____________________________________________________________

Relationship_____________________________

Address________________________________City_______________State________

Zip______________

Home phone______________________work phone___________________

3. Name_____________________________________________________________

Relationship_____________________________

Address________________________________City_______________State________

Zip______________

Home phone______________________work phone___________________

Father or Stepfather name________________________________________

Street Address___________________________________________________

City ________________________State__________ ZIP_____________

Home phone( ) ________-_________ work phone ( )__________-________

Father’s Employer________________________________________________

Mother or Stepmother name________________________________________

Street Address___________________________________________________

City _____________________State___________ Zip________________

Home phone( )__________-_________ work phone ( ) __________-_________

Mother’s Employer_____________________________________

Education

Name of High School________________________________________

City___________________________ State____________________

Dates Attended____________ to ______________ ______ High School Diploma? ________GED? _____ None

Extracurricular activities in High School and/or college ______________________________________________________________________________________________________________________________________________

Will you need housing assistance while attending school?

_____ yes _______no

How did you hear about us? ______TV ______Internet _____Yellow pages _____Brochure ____________other

Do you have any health problems that would inhibit you from working with animals? (such as back problems or allergies).____________________

Person(s) to Contact in Case of Emergency (other than references):

Name__________________________________________

Relationship_________________________

Address________________________________city___________________st______

zip____________ Home Phone ( ) _______________________ work Phone ( )____________________________

Name__________________________________________

Relationship_________________________

Address________________________________city___________________st______

zip____________ Home Phone ( ) _______________________ work Phone ( )____________________________

I hereby certify that the information above is complete and accurate to the best of my knowledge

_______________________________________________________________________

Student Signature Date

Enclosed is my deposit of $500 by check number __________.(If credit card, see below). Please reserve a place for me in your class starting _______- _______ -_________. I understand that a minimum of $900 is due on or before the first day of class. (Payment arrangements will be made with Manager). I also understand that my deposit is fully refundable before the first day of class if I can not attend (minus supplies received), or that I may apply it to a class at a later date.You may also make a payment through www.paypal.com to asmartk9@aol.com but there is a 1.5% fee.

_________________________________ _________________________

Signature Date

Preferences____________ Full time Days _____________ Part Time Days _____________ Part Time Nights _____________ Nights/ Saturday

Please charge my ____________visa _______________ mastercard _____________discover

card number______________________________________ expiration ________/________

Name on credit card as it appears__________________________________________________

____________________________________________ _________________________

Signature of Cardholder Date

Remit this application to: Smartk9 Academy PO Box 762
Gilbert, AZ 85299
Phone 480.620.3859 if any questions.