PhD Committee Petition
The Committee on the PhD Program
Date:_____________________________ Name: ____________________________
Email:____________________________ Mailing: Address:___________________________
Statement of Petition
(Continue on or attach additional sheets of paper.)
� I give my consent to the student representatives being present when
this petition is reviewed.
� I do not give my consent to student representatives being present.
Note: If neither box is checked, it is assumed that consent is given for
student representatives to be present.
Faculty Endorsements: (Note that an email approval from the faculty member to Jenifer B-P will be
accepted in lieu of a hard copy signature.)
___________________________________ ___________________________________
___________________________________ ___________________________________
___________________________________ ___________________________________
Signature
Name (printed)
Committee Action:
Approved: ____________ Denied: _____________ Deferred:____________
Date:
Remarks:_____________________________________________________________________
_____________________________________________________________________________
______________________________________________
Jenifer Burckett-Picker, Director of the PhD Program