Approval Form

First Name
Last Name
KSU CVM Class of
Student's E-Mail Address
Number Of Full Weeks
Dates of Mentorship
Semester you would like to be enrolled in this mentorship (this is when you will be charged tuition for the course)		Spring Summer Fall
Mentor's Name must be a Veterinarian
Practice Name
Mentor's Mailing Street Address
Mentor's City
Mentor's State
Mentor's Zip Code
Mentor's Phone (###-###-####)
Mentor's Email
Mentorship Type		Food Animal / Mixed (CS766) Small Animal (CS 767) Non - Traditional / Alternative / Equine (CS 768)
Practice Description

Have you discussed the expectations of this mentorship with the above listed mentor?
Yes No

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