Last Name ______________________________ First Name ____________________

Student ID ________________________________

Current Address ____________________________________________________________

__________________________________________________________________________

Telephone Number _____________________

E-mail Address ________________________

My current GPA is _____________

This form should be submitted to the department office at the beginning of the Fall or Spring semesters along with the Ph.D. Qualifying Project Report. As a part of the Ph.D. Qualifying Exam every student is required to take an oral exam. The department will notify students of the exact date for the oral exam. Each student is also required to submit 3 copies of his/her Ph.D. Qualifying Exam Project Report at the beginning of the Fall or Spring semesters.

Student Signature ________________________________________ Date __________

Faculty Member's Signature _______________________________ Date ___________