Name:* First Last Please provide your complete name that you want on your graduation certificate, as well as any professional credentials such as RN, RD, or Ph.D, that you may already have. If you change your name prior to your class, please let us know immediately. We make the certificates as soon as the class is filled and we need everyone's correct name.Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number* Email address* For which class are you applying?*Autumn 2022Winter/Spring 2023Summer 2023How did you hear about Main Street Vegan Academy?*If an individual referred you please list name so we can thank them. How long have you been vegan? What sparked your interest in the vegan lifestyle?Please note that YOU MUST BE A DIETARY VEGAN -- NO MEAT, FOWL, FISH, EGGS OR DAIRY PRODUCTS -- TO BE ACCEPTED INTO THIS PROGRAM. If you are still transitioning away from non-vegan clothing, etc., this is not a problem.Why do you wish to become an MSV-certified Vegan Lifestyle Coach and Educator?I am a dietary vegan* Yes No If some emergency keeps me from participating, I agree I will receive a refund less a $150 processing fee* Yes No I understand that Main Street Vegan Academy makes no guarantee to any student that he or she will be able to turn the certification that results from this course into a successful business or side business, although some graduates have done this.* Yes No Your Digital Signature (Please type your full name)* My digital signature above confirms that: (1) I am a dietary vegan. (2) If some emergency keeps me from participating, I will receive a refund less a $150 processing fee. (3) I understand that Main Street Vegan Academy makes no guarantee to any student that he or she will be able to turn the certification that results from this course into a successful business or side business, although some graduates have done this. (4) Main Street Vegan Academy certification does not qualify me to diagnose or treat any mental or physical malady via dietary or other means. I understand that this is not a medical or allied health training program and unless I am otherwise duly licensed as an MD, DO, RN, RD, or other recognized professional, I cannot attempt or promise to address any illness. If any person under the care of a physician or on taking any medication comes to me for Vegan Lifestyle Coaching, I will require the knowledge and sanction of this person's physician before talking with him/her about any dietary changes.