Student Externship Placement
Please Select Your Course
Please Select
Clinical Medical Assistant
Phlebotomy Technician
Dental Assistant
Pharmacy Technician
Campus Information:
Externship Coordinator:
First Name
Last Name
Coordinator Phone Number:
Please enter a valid phone number.
Student Name:
First Name
Last Name
Student Phone Number:
Please enter a valid phone number.
Student Email
example@example.com
Placement Information:
Facility/Office of Placement:
Doctor/Contact Person:
Address of Office:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Facility Phone Number
Please enter a valid phone number.
Hours of Operation:
Start Date:
-
Month
-
Day
Year
Date
Start Time:
Hour Minutes
AM
PM
AM/PM Option
Orientation/Interview Required:
Please Select
Yes
No
Date
-
Month
-
Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Student Accepted Externship:
Please Select
Yes
No
If Rejected: Student must give reason why and their plan for completing externship:
Signature
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