INTERN / EXTERN APPLICATION
PRINT and mail to:
Gayle S. Leith, D.V.M. M.S.
P.O. Box 749
Gilbert, Arizona 85299
Name:____________________________________ Telephone:_______________________
Address:____________________________________ State:____________ Zip:__________
Email:__________________________________ AVMA#:___________________________
Name, address, and telephone number of another individual to contact in case of emergency:
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Dates desired for externship:
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Specific areas of interest:
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Specific goals for this externship:
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At the time of your desired dates, you will be a (please circle one):
FRESHMAN SOPHOMORE JUNIOR SENIOR
Will your equine rotation/block be completed before your desired dates? YES NO
Briefly describe any equine experience you have:
_________________________________________________________________
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Name, address, and telephone number of two professional references:
_________________________________________________________________
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