College of Veterinary Medicine

APPROVAL FORM FOR ELECTIVE
(EXTERNSHIP)
OFF-CAMPUS ROTATION

NO RETROSPECTIVE APPROVALS

To submit at the bottom, please be sure you type in all letters correctly, otherwise your work will be lost.

Externship for Elective Credits

Primary Care Externship

Name:

Number of full weeks:

Dates:

Rotation:

Externship's Name/Address/Website:
(Complete address)

Name:

Address:

Website:

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:

Kansas State University