ࡱ> ?A>5@ %bjbj22 -&XX rrrrrrr  0 rtttI$ R#ErJY|JJrr kFJ r r rJrF0rTrr d T.>4\0#^#rrrr#r8_g$   UNIVERSITY OF MEDICINE AND DENTISTRY OF NEW JERSEY NEW JERSEY MEDICAL SCHOOL Registrars Office Phone (973) 972-4640 PO Box 1709, 185 South Orange Avenue MSB B-640 Fax (973) 972-6930 Newark, New Jersey 07101-1709 Request for Approval of 3rd or 4th Year Externship Application Information (To be completed by student. Please print.) __________________________________________________ _________________________ ________________ (Student Name) (S.I.N.) (Class) ______________________________________________________________________________________________________ (Host Institution/Hospital Name and Full Address) (Street, City, State, Zip) __________________________________________________ __________________________ _________________ (Title of Externship) (Sponsor/Supervisors Name) (Dates of externship) ______________________________________________________________________________________________________ (Brief description of the Externship: Please attach additional descriptive information if available i.e. course description) __________________________________________________________________________________________________________________________ (Is the address listed above the location of the activity? If yes, please indicate. If no, please provide location address.) _______________________________________ ________________ (Student signature) (Date)  B. Pre-Approval (To be completed by NJMS Department Chair) Please check one of the following: % Pre-Approved % Denied _________________________________________ _________________________ _________________ (Chairperson Signature and Title) (Extension) (Date)  Registrar Office Certification (To be completed by NJMS Registrars Office) This student is in good academic standing and has obtained permission to apply for the externship identified above. _________________________________________ __________________________ (Asst. Dean/Registrar signature) (Date)  D. Host Institution Approval (To be completed by Host Institution Sponsor) Choose one: % This student has been accepted for placement into the above-mentioned externship. % This student has not been accepted for placement into the above-mentioned externship % Acceptance letter attached. ______L`a    ! = j      G 2 ? a c z z ǺаЪztfh hV56CJaJ hVCJ hk 6CJhV56CJh`56CJhk 56CJ hk 6CJ hk 5CJ hk CJhk 56CJ H*h+4h+456CJ H*h+456CJ hk 56CJ hk CJhVhk CJaJhVhk 5CJaJhk hk 5$3M`a ! " i j k   G H z  & F Hd d^`d`d$ 8a$%z z { uv .}~DE^ & F h8^8` `d^``gdVz { uv .x}~E˹˲}}yyԲr}^}WrWW hk 5CJ'jhk 56CJUhmHnHu hk 6CJhk hk 56CJhk 5CJOJQJ,jhk 5CJOJQJUhmHnHuhk CJOJQJ hk 5CJh 56CJho656CJhk 56CJ hk CJ hVCJh hV56CJaJhVCJaJhV6CJaJ":$b$$$$$$$$%%%%ƫƤhVhVCJaJ hV5CJ$jhk 5CJUhmHnHuU hk CJ hk 5CJ hk 6CJ$jhk 6CJUhmHnHu hk 6CJhk 56CJho656CJ<>XZb$$$$$% $`^``a$^___________________________________ ___________________________ __________________ (Sponsor signature) (Sponsor name please print.) (Date)  Please note: After completion of Steps B. and D., this form should be forwarded to the NJMS Registrars Office for processing. Steps A. through D. must be completed no later than four (4) weeks prior to the start date of the externship. Thank you. Cc: Student file, Sponsor +0PBP/ =!"#$%D@D Normal1$CJ_HhmH sH tH B@B Heading 1 $1$@& 5huL@L Heading 2$$1$@&a$ 5CJhu<@< Heading 3$@&5CJH@H Heading 4$@ @&^@ `6L@L Heading 5$$d@&a$ 5OJQJ<@< Heading 6$@&5CJ DA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List <&@< Footnote Reference@>@@ Title $1$a$56CJ huBB@B Body Text $1$a$ 5hu>P@"> Body Text 2$da$NS@2N Body Text Indent 3$`a$H@BH  Balloon TextCJOJQJ^JaJ &3M`a !"ijkGHzz{uv hi} ~ D E   , - b 000000000000 000000(00000000 000000000000000 0000 0 0 00 0000 0 0 0 00 00 0 000000z % z % % 8@"(  \B  S D1"\B  S D1"\B  S D1"\B  S D1"B S  ?~ &t"&"tM&Mt&tH!HHT!HqH̄HDnH}HDHęHH}#HD}#HNH<H!H|#,77>Fjk       2=ELL   =*urn:schemas-microsoft-com:office:smarttags PlaceType=*urn:schemas-microsoft-com:office:smarttags PlaceName9*urn:schemas-microsoft-com:office:smarttagsplace;*urn:schemas-microsoft-com:office:smarttagsaddress8*urn:schemas-microsoft-com:office:smarttagsCity9*urn:schemas-microsoft-com:office:smarttagsState>*urn:schemas-microsoft-com:office:smarttags PostalCode:*urn:schemas-microsoft-com:office:smarttagsStreet  0 4 333ZHLuv  Harvey ErdsnekerHarvey ErdsnekerHarvey ErdsnekerHarvey ErdsnekerHarvey ErdsnekerHarvey ErdsnekerHarvey ErdsnekerHarvey ErdsnekerNJMSfergusjeG.0g qwhyLD{ hh^h`o(.^`o(.0^`0o(.hh^h`o(.qwh0gGD{ k +4o6@qPV`EMvE %0@HP LaserJet 4050 Series PCL6LPT1:winspoolHP LaserJet 4050 Series PCL6HP LaserJet 4050 Series PCL64C odLetter DINU"4~qHP LaserJet 4050 Series PCL64C odLetter DINU"4~qMg@ @$@H@UnknownGz Times New Roman5Symbol3& z ArialCFComic Sans MS5& zaTahoma" h ҊF⊆⊆  ! 2d 3 H(?+42UNIVERSITY OF MEDICINE AND DENTISTRY OF NEW JERSEYnjmsfergusje    Oh+'0  , H T ` lx3UNIVERSITY OF MEDICINE AND DENTISTRY OF NEW JERSEYNIVnjmsRSIjmsNormalI fergusjeY O5rgMicrosoft Word 10.0@J6@LD@"T@ ՜.+,0  hp  umdnjI A 3UNIVERSITY OF MEDICINE AND DENTISTRY OF NEW JERSEY Title  !"#$%&'()*+,-/012345789:;<=@Root Entry F BData 1Table#WordDocument-&SummaryInformation(.DocumentSummaryInformation86CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q