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APPROVAL FORM FOR ELECTIVE
(EXTERNSHIP)
OFF-CAMPUS ROTATION
NO RETROSPECTIVE APPROVALS
Externship for Elective Credits
Primary Care Externship
Name:    
Number of full weeks:    
Dates:    
Externship's Name/Address/Website:
(Complete address)
Name:
Address:
City:  
State:  
Zip code:  
Website:  
Do you plan to drop an existing scheduled elective:
Number of days you will spend with the veterinarian:
How many total hours will be spent with the veterinarian:  
Number of credits you are requesting for this experience:  
If your total elective credits exceed 11 with this experience, do you plan to pay for those credits exceeding the required 11:  
Summarize what you will be doing:


 

Justification:

How does this fit your future plans?

Additional Information?

Name of the doctor who will serve as evaluator (please list credentials):

Phone:

e-mail:

 

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