http://www.bloomu.edu/documents/coe/Student_Teaching_Packet.pdf
STUDENT TEACHING APPLICATION
Early Childhood PK-4/Middle Level 4-8, Secondary Education,
Dual Special Education PK-8/Early Childhood PK-4 and
Deaf Hard of Hearing
Candidates applying for student teaching must meet eligibility requirements and submit required
documentation to the Office of Field Experiences (McCormick 3103-C) by the following due dates:
Fall Student Teaching Placement – All documentation due April 10th
Spring Student Teaching Placement – All documentation due October 1st
Student Teaching Eligibility Requirements:
1.
2.
Application for Graduation – completed and signed by your advisor
*Tuberculosis (TB) Results – must be valid for the duration of the student teaching semester
(Attach 3 copies)
3. **Act 34 (Criminal Record Check) – must be valid for the duration of the student teaching semester
(https://epatch.state.pa.us/) (Attach 3 copies)
4. **Act 151 (Child Abuse History) – must be valid for the duration of the student teaching semester
(Attach 3 copies) (https://www.compass.state.pa.us/cwis/public/home)
5. **Act 114 (Federal Criminal History) – must be valid for the duration of the student teaching semester
(http://www.cogentid.com/index.htm) must register through Department of Education (Attach
Registration Receipt ONLY) after fingerprinted.
6. **Act 24 (Arrest/Conviction Report and Certification Form) (Attach 3 copies)
7. Professional Liability Insurance – must be valid for the duration of the student teaching semester and
must meet a minimum of $1,000,000.00 per claim and $3,000,000.00 aggregate (http://www.psea.org)
(Attach 3 copies)
8. Resume
9. Student Teaching Placement Agreement – signed and dated
10. ***Act 126 (Mandated Child Abuse Reporting – obtained through www.reportabusepa.pitt.edu Free OnLine training or register through Bloomsburg University for the amount of $20.00 for a more in-depth
training session (Print Certificate) (Attach 3 Copies)
*TB Results are valid for ONE year from screening results date. NOTE: Some Districts may require it to
be within 3 months prior to placement start date. You will be notified once placement has been
confirmed.
**Act 34, 151, 114 are valid for ONE year from date issued.
Any infraction reported on any clearance will result in the placement process being delayed. Candidates
will be notified and be responsible to schedule a Program Review Counseling Session with the College of Education’s
Assistant to the Dean where information and guidance will be provided to assist the candidate in understanding
how infractions may affect student teaching placement, program progression, certification, and future employment
success.
***Act 126 – valid for FIVE years from date issued.
Revised Spring 2010/Spring 2012/Spring 2013/Fall 2013/Fall 2014/Fall 2015/Spring 2016
Student Teaching Application and Verification of Eligibility
Early Childhood PK-4/Middle Level 4-8, Secondary Education,
Dual Special Education PK-8/Early Childhood PK-4 and
Deaf Hard of Hearing
Candidates are responsible for completing student teaching eligibility requirements and are expect to meet with their
designated academic advisor(s) for program guidance and verification that application requirements have been met. It is
then the responsibility of the candidate to deliver this application, completed and with advisor’s signature, to the Office of
Field Experiences (McCormick 3103-C) by the appropriate date:
Fall student Teachers – April 10th
Spring Student Teachers – Due October 1st
Candidate’s Name: ___________________________________________ Identification Number ____________________
Eligibility for Student Teaching is contingent upon evidence of the following:
________1.
Professional Liability Insurance (Attach 3 copies)
Options: private carrier, professional organizations or PSEA (http://www.PSEA.org)
________2.
Documentation of Act 34 (Criminal Record Check) – must be valid for duration of student teaching or
practicum semester (Attach 3 copies) (http://epatch.state.pa.us)
________3.
Documentation of Act 151 (Child Abuse History) – must be valid for duration of student teaching or
Practicum semester (Attach 3 copies)
________4.
Documentation of Act 114 (Federal Criminal History) – must be valid for duration of student teaching or
practicum semester (Attach Registration Receipt ONLY) after fingerprinted. Register at
(http://www.pa.cogentid.com) MUST register through, “The Department of Education”.
________5.
Documentation of Act 24 (Arrest/Conviction Report and Certification Form - student teacher eligibility
(Attach 3 copies)
________6.
Documentation of tuberculosis test results (TB) (Attach 3 copies)
________7.
Updated resume
________8.
Application(s) for Graduation (Attach signed application) Secondary Education candidates will need a
signed application from two advisors (ESSE program/content major)
________9.
Documentation of Act 126 (Mandated Child Abuse Reporting) – (Attach 3 copies)
________10. GPA: ______
________11. BASIC SKILLS: ____PASSED
____NOT PASSED
____SAT _____ACT
The following signature attests that all documents are accurate, updated and attached:
__________________________________
Advisor/Faculty/Coordinator
_______________
Date
__________
Conditional Recommended (If check, explain below)
The following Signature attests that all conditional requirements have been met.
_________________________________
Department Chairperson
_______________
Date
Revised Spring 2010/Spring 2012/Spring 2013/Fall 2013/Fall 2014/Fall 2015/Spring 2016
http://www.bloomu.edu/documents/coe/Student_Teaching_Packet.pdf
College of Education
Student Teaching Agreements
Please read the student teaching terms below. Provide the requested information, initial, and sign
where indicated to acknowledge your agreement to the terms and deadlines.
I, ________________________________________ hereby acknowledge to the Office of Field
Experiences, Bloomsburg University of Pennsylvania:

that I have read and understand that the Student Teaching Eligibility Packet deadline is firm as set
forth in the packet. I bear all responsibility for the submission of my student teaching packet by the
deadline date being considered for student teaching. ________
(initial)

that I give consent to the Office of Field Experiences to release any and all records it
may have in its possession to a school district or other site in which I may be placed for student
teaching or practicum in order to prove my qualifications. I realize that such records may include and
not be limited to, academic (GPA and courses completed), health (TB screening results), Act 34, Act
151, and Act 24 clearances and disciplinary records, as well as my social security number and
Bloomsburg University of Pennsylvania identification number for identification purposes.
Bloomsburg Univesrity will supply the Act 114 Registration ID# to the District only. This release
will expire upon commencement from Bloomsburg University of Pennsylvania or after completion of
(initial)
student teaching or practicum, whichever is later. _______
 that as an enrolled student at Bloomsburg University of Pennsylvania, I have read and will comply
**************************
with : College of Education, Admission, Monitoring and Monitoring and Exit Procedures
for Teacher Education Initial Certification Programs, College Policy 3.0
(http://www.bloomu.edu/documents/coe/PolicyHandbook.pdf) _________
(initial)
I realize that by signing the above acknowledgments, I agree to adhere to the terms and deadlines set forth
and failure to do so will result in the postponement of my student teaching experience.
Candidate’s Signature:
______________________________________________________
Candidate’s Printed Name:
______________________________________________________
Date: ____________________
Revised Spring 2010/Spring 2012/Spring 2013/Fall 2013/Fall 2014
Teacher Candidate Placement Agreement
This agreement is entered in between _____________________________ and the Office of
Field Experiences at Bloomsburg University of Pennsylvania, located in the McCormick Building, third
floor. Bloomsburg University of Pennsylvania has a great reputation for placing our teacher candidates
in a variety of districts in which we have fully signed/executed affiliation agreements in place. The
Office of Field Experiences will do everything possible to assure the experience is successful and positive
for our aspiring teacher candidates.
We cannot guarantee you will be placed within a 30-mile radius of your residency. Your student
teaching placement may be up to 2 hours from the address you provided on the Student Teaching
Placement Card (Application for Student Teaching). There may be isolated situations where housing on
campus is necessary in order to provide a placement for you. If you change your place of residency, you
MUST contact the Office of Field Experiences immediately at amccabe@bloomu.edu or 570-389-5128.
(Fall – Prior to May 1st; Spring – Prior to October 1st).
Direct contact to districts, initiated by you, family or someone on your behalf can result in
termination of student teaching placement for a semester. It is the Field Experience Placement Office’s
policy that all agreements and affiliations with district placements are conducted through the Office of
Field Experiences ONLY. We value the support and relationships of our participating school partners
and are honored to continue placing quality, professional teacher candidates in their facilities.
Thank you for understanding and acknowledging this agreement. The professional growth and
quality experience that you will gain through your placement will contribute greatly to the effectiveness
of your career. The Office of Field Experiences is always opened to provide you with support and
guidance. Be a lifelong learner, it is the continual knowledge you seek that will enhance the students
your encounter and prepare you for the continuous changes in the education profession.
Thank you,
Candy Ryan
Director of Field Experiences
I have carefully read the above contract and agree to abide by the terms listed:
Signature: ____________________________
Date:____________________________
1 of 3
ARREST/CONVICTION REPORT AND CERTIFICATION FORM
(under Act 24 of 2011 and Act 82 of 2012)
Section 1.
Personal Information
Full Legal Name:
Date of Birth: _____/_____/________
Any former names
by which you have
been identified:
Section 2.
Report of Arrest or Conviction
By checking this box, I report that I have been arrested for or convicted of an offense or offenses
enumerated under 24 P.S. §§1-111(e) or (f.1) (“Reportable Offense(s)”). See Instructions on Page 3 of this Form for
a list of Reportable Offenses. If you have none to report, proceed to Section 3 of this form.
Details of Arrests or Convictions
For each arrest for or conviction of any Reportable Offense, specify in the space below (or on
additional attachments if necessary) the offense for which you have been arrested or convicted, the
date and location of arrest and/or conviction, docket number, and the applicable court.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Section 3.
No Arrest or Conviction
By checking this box, I state that I have not been arrested for or convicted of any Reportable
Offense.
Section 4.
Certification
By signing this form, I certify under penalty of law that the statements made in this form are true, correct and complete. I
understand that false statements herein, including, without limitation, any failure to accurately report any arrest or conviction for a
Reportable Offense, shall subject me to criminal prosecution under 18 Pa.C.S. §4904, relating to unsworn falsification to
authorities.
Signature
PDE-6004 (8/28/2012)
Date
2 of 3
INSTRUCTIONS
This standardized form (PDE-6004) has been developed by the Pennsylvania Department of Education, pursuant to
24 P.S. §1-111(j), to be used by current and prospective employees of public and private schools, intermediate units
and area vocational-technical schools for the written reporting by current and prospective employees of any arrest or
conviction for an offense enumerated under 24 P.S. §§1-111(e) and (f.1).
As required by subsection (j)(2) of 24 P.S. §1-111, this form shall be completed and submitted by all current and
prospective employees of a public or private school, intermediate unit or area vocational-technical school. In
addition, as required by subsection (j)(4) of 24 P.S. §1-111, this form shall be utilized by current and prospective
employees to provide written notice within seventy-two (72) hours after an arrest or conviction for an offense
enumerated under 24 P.S. §§1-111(e) or (f.1).
Exemption: Any current employee who completed a PDE-6004 on or before December 27, 2011, in compliance
with 24 P.S. §§1-111(j)(1) and (2) on that date, and who has not been arrested for or convicted of an offense
enumerated under 24 P.S. §§1-111(e) and (f.1) shall not be required to complete an additional form.
In accordance with 24 P.S. §1-111, employees completing this form are required to submit the form to the
administrator or other person responsible for employment decisions in a school entity.
If you have questions regarding to whom the form should be sent, please contact your supervisor or the school entity
administration office.
PROVIDE ALL INFORMATION REQUIRED BY THIS FORM LEGIBLY IN INK.
PDE-6004 (8/28/2012)
3 of 3
LIST OF REPORTABLE OFFENSES

A reportable offense enumerated under 24 P.S. §1-111(e) consists of any of the following:
(1)

















(2)
An offense under one or more of the following provisions of Title 18 of the Pennsylvania Consolidated
Statutes:

Section 4304 (relating to endangering
welfare of children)

Section 4305 (relating to dealing in infant
children)

A felony offense under section 5902(b)
(relating to prostitution and related
offenses)

Section 5903(c) or (d) (relating to obscene
and other sexual materials and
performances)

Section 6301(a)(1) (relating to corruption
of minors)

Section 6312 (relating to sexual abuse of
children)

Section 6318 (relating to unlawful contact
with minor)

Section 6319 (relating to solicitation of
minors to traffic drugs)

Section 6320 (relating to sexual
exploitation of children)
An offense designated as a felony under the act of April 14, 1972 (P.L. 233, No. 64), known as
“The Controlled Substance, Drug, Device and Cosmetic Act.”
Chapter 25 (relating to criminal homicide)
Section 2702 (relating to aggravated assault)
Section 2709.1 (relating to stalking)
Section 2901 (relating to kidnapping)
Section 2902 (relating to unlawful restraint)
Section 2910 (relating to luring a child into a motor
vehicle or structure)
Section 3121 (relating to rape)
Section 3122.1 (relating to statutory sexual assault)
Section 3123 (relating to involuntary deviate sexual
intercourse)
Section 3124.1 (relating to sexual assault)
Section 3124.2 (relating to institutional sexual assault)
Section 3125( relating to aggravated indecent assault)
Section 3126 (relating to indecent assault)
Section 3127 (relating to indecent exposure)
Section 3129 (relating to sexual intercourse with animal)
Section 4302 (relating to incest)
Section 4303 (relating to concealing death of child)
(3) An offense SIMILAR IN NATURE to those crimes listed above in clauses (1) and (2) under the
laws or former laws of:
• the United States; or
• one of its territories or possessions; or
• another state; or
• the District of Columbia; or
• the Commonwealth of Puerto Rico; or
• a foreign nation; or
• under a former law of this Commonwealth.

A reportable offense enumerated under 24 P.S. §1-111(f.1) consists of any of the following:
(1) An offense graded as a felony offense of the first, second or third degree, other than one of the
offenses enumerated under 24 P.S. §1-111(e), if less than (10) ten years has elapsed from the date
of expiration of the sentence for the offense.
(2) An offense graded as a misdemeanor of the first degree, other than one of the offenses enumerated
under 24 P.S. §1-111(e), if less than (5) five years has elapsed from the date of expiration of the
sentence for the offense.
(3) An offense under 75 Pa.C.S. § 3802(a), (b), (c) or (d)(relating to driving under influence of
alcohol or controlled substance) graded as a misdemeanor of the first degree under 75 Pa.C.S. §
3803 (relating to grading), if the person has been previously convicted of such an offense and less
than (3) three years has elapsed from the date of expiration of the sentence for the most recent
offense.
PDE-6004 (8/28/2012)
Bloomsburg University of Pennsylvania
Commencement Office
Carver Hall
APPLICATION FOR GRADUATION
(UNDERGRADUATE)
INSTRUCTIONS: A candidate for a bachelor’s degree must complete the front of this form and submit to
his/her department for verification of degree requirements. Secondary Education, double major, and dual
degree students must submit two applications. The department/s will then review and approve/deny and
submit the application to the Graduation Coordinator. If you have NOT met all requirements for graduation,
your department will notify you.
MAY GRADUATION:
Deadline for student submission of this form is FEBRUARY 1 in order to be eligible to participate in the commencement ceremony,
for your name to be listed in the commencement program, for recognition of honors at the ceremony, and for a diploma to be
ordered in your name. The department must submit this application to the Graduation Coordinator by MARCH 15.
*AUGUST GRADUATION:
(There is no August commencement ceremony. Instead, August degree candidates may elect to “walk” in the May ceremony or to
“walk” in the December ceremony. Select choice below.)
Deadline for student submission of this form is MARCH 1 in order to be eligible to participate in the commencement ceremony, for
your name to be listed in the commencement program, for recognition of honors at the ceremony, and for a diploma to be ordered in
your name. The department must submit this application to the Graduation Coordinator on or before APRIL 1.
DECEMBER GRADUATION:
Deadline for student submission of this form is OCTOBER 1 in order to be eligible to participate in the commencement ceremony,
for your name to be listed in the commencement program, for recognition of honors at the ceremony, and for a diploma to be
ordered in your name. The department must submit this application to the Graduation Coordinator on or before NOVEMBER 1.
*************************************************TO BE COMPLETED BY STUDENT *****************************************

_________________________________________________________________
PRINT your name as you want it to appear on your diploma and in the
commencement program
Student ID Number
PHONE: (__ __ __) __ __ __ - __ __ __ __ (Where you can be reached if there are questions about your graduation.)
E-MAIL ADDRESS:
_______________________________________________________________________________________
Which semester will you complete all requirements for your degree? (If this date changes, contact the Graduation Coord.)
❐ Spring Semester 20_____
❐
*Summer Semester 20____
❐ Fall Semester 20____
AREA OF STUDY: Indicate your major, with concentration area if appropriate. (List only one major on this form. Complete
another application if you are in secondary education, a double major or a dual degree student.)
Business:
Major: ______________________________________________________________
Liberal Arts:
Major: ______________________________________________________________
Education:
Major: ______________________________________________________________
Sec. Ed. – 2nd Major: ______________________________________________
Science & Technology:
Major: ______________________________________________________________
DO YOU PLAN TO PARTICIPATE IN THE COMMENCEMENT CEREMONY?
(If neither box is checked, your name will be recorded as not participating.)
❐ YES
❐ NO
*AUGUST GRADUATES:
 Not participating
Which ceremony do you plan to attend:  May
 December
Student Name: ____________________________________________________________________________________
Last
First
MI
************************************************** DEPARTMENT APPROVAL********************************************************
(This section is to be completed by the department of the major noted on the reverse.)
DEGREE PROGRAM:
❐ BA
❐ BS
❐ BSBA
❐ BSED
❐ BSN
❐ BSW
MAJOR (INCLUDE CONCENTRATION): ___________________________________ Cum. Credits Earned: _____
❐ YES
❐ NO, give explanation below
1.
Will all curricular requirements for the MAJOR be completed by the time of graduation?
2.
Has student taken developmental studies courses numbered 001 – 099?
3.
Will all requirements for the following General Education SPECIFIC areas be completed by the end of the semester indicated
on the reverse?
4.
5.
❐ YES (Credits do not count toward graduation) ❐ NO
a.
COMMUNICATION
❐ YES
❐ NO, give explanation below
b.
QUANTITATIVE - ANALYTICAL REASONING
❐ YES
❐ NO, give explanation below
c.
VALUES, ETHICS & RESPONSIBLE DECISION MAKING
❐ YES
❐ NO, give explanation below
d.
FITNESS & RECREATIONAL SKILLS
❐ YES
❐ NO, give explanation below
Will all of the following General Education DISTRIBUTION Requirements be completed by the end of the semester indicated?
a.
GROUP A - HUMANITIES
❐ YES
❐ NO, give explanation below
b.
GROUP B - SOCIAL & BEHAVIORAL SCIENCES
❐ YES
❐ NO, give explanation below
c.
GROUP C - NATURAL SCIENCES AND MATHEMATICS
❐ YES
❐ NO, give explanation below
Will the Cultural Diversity Requirement be completed by the end of the semester indicated?
❐ YES ❐ NO, give explanation below
6.
At this time, does the candidate have the following:
a. 2.00 grade point average in all courses for the MAJOR?
❐ YES ❐ NO
(THE REQUIRED GPA IN SOME DISCIPLINES MAY BE HIGHER THAN 2.0)
b. 2.00 cumulative grade point average in all courses?
❐ YES ❐ NO
7.
Are there any outstanding grades of I and/or R that need to be completed?
❐ NO
8.
Are there any outstanding transfer credits that are required for the degree?
❐ YES
❐ NO ❐ YES, Prior Approval of Transfer Credit form completed
IT IS THE RESPONSIBILITY OF THE ADVISOR OR DEPARTMENT CHAIRPERSON TO NOTIFY
THIS DEGREE CANDIDATE OF ANY COURSE DEFICIENCIES OR IF GRADUATION APPROVAL IS DENIED.
❐ I certify that this student is cleared for graduation, with the successful completion of the current semester
(and/or the courses noted below).
❐ This candidate is NOT cleared for graduation.
❐ Student
was notified.
DEPARTMENT APPROVAL: _____________________________________________________ DATE: _________________________
CHAIR OR DESIGNEE
Explanation of course requirement/s to be completed before bachelor’s degree can be granted:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
APPLICATION FOR GRADUATION for MASl ' ER' S, DOCTORATE, OR GRA DUATE CERTIFICATES I NSTRUCTIONS: This form is to be used only if you are rea dy to graduate with one of the degrees/certificates listed above. A candidate for a master' s/doctorate/certificate program must complete the student portion of this form , sign, and submit it to their program coordinator [or verification o[degree requirements. Once approved, the program coordinator must forward it directly to the Graduate Office (with the appropriate program check sheet) by the deadline listed below for each degree (regardless if you are or are not participating in a commencement ceremony) . MAY DEGREE:
~
The application must be in the Graduate Office on or before MARCH 15. After this deadline,
names may not be placed in the commencement program. Diploma will be delayed.
AUGUST DEGREE:
*(There is no August commencement ceremony. August degree candidates, may "walk " in the May
ceremony or participate in the December ceremony.)
~ The
application must be in the Graduate Office on or before APRIL 1 for participation in May
ceremony. After this deadline, names may not be placed in the commencement program. Ifnot
participating in the May ceremony, the application must be in the Graduate Office by August I.
DECEMBER DEGREE:
~
The application must be in the Graduate Office on or before OCTOBER 15. After this deadline,
names may not be placed in the commencement program. Diploma will be delayed.
PAR TICIPA TION IN THE COMMENCEMENT CEREMONY DOES NO T CONS TITUTE VERIFICA TION OF GRADUATION. A STUDENT MUST SATISFACTORILY COMPLETE ALL REQUIREMENTS BEFORE A DEGREE IS AWARDED. Failure to meet the requirements by the semester indicated on the submitted application will require
resubmission ofa new "Applicationfor Graduation " for whenever requirements will be met.
Visit the Registrar's web page for Graduation/Cerem ony informatio n:
http://www.bloomu.edu/registrar.
See other side
Rev. 10/08
..
APPLICATION FOR GRADUATION
(Master's, Doctorate or Graduate Certificates)
********************************* TO BE COMPLETED BV STUDE NT***** ******* ******** *************
DDDDDD
BU Student 10 PRINT NA ME (as you would like it to appear on your diploma)
Which sem ester will you complete all requirements (including departmental paper, thesis, internship, etc.) for your degree? (Fai lure to
meet the requirements by the semester checked below will require you to reapply when requirements will be meL)
rJSpring Semester (May) 20 _ _ D*Summer Semester (August) 20 _ _
._------- - - - - - - - - - - - - - - ­
D Fall Semester (December) 20_ _
l
!
. Program of Study: _ _ __ _ _ _ __ _ __ _ _ _ _ _ _ _ _ _ _ ___ __ _ _ __ _ __ _ __
I
I Degree/certi fi ca te be ing sou ght :_ _ _ _ _ _:-:-::----:-:-:--:-::-_-::-:-:-----::---_--:-::-_-::-:_----:-::-_
_ _-,---_
_ _ __ _ (MS.. M.Ed., MBA, MSN , AuD, or certificate/li st certificate program) 00 you plan to participate in graduation: Wear a cap and gown, march with the class, receive yo ur diploma cover and
be hooded on stage? aVES 0 NO (If there is not a box checked . your name will be recorded as NOT participating.)
"'August Graduates: Which ceremony do you plan to attend : OMay 20 0
Dr do not plan to attend any ceremony.
DDecember 20 CI
Theses presented for degrees are printed in the commencement program. If applicable, please PRrNT the title of thesis and
name of your thes is advisor here:
THESIS TITLE: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
THESIS ADVISOR:_ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ __ _ _ _ _ _ _ _ _ __
I X- - - - - - ­
- S- t-u-d-en-t- '-s-S-ig-n-a-tu- r-e- - - ­ - - - - - - - - - ­
DATE:_ _ __ _ _ _ __ _ __
•••••••••••••••••...···················TO BE COMPLETED BY PROGRAM COORDINATOR FOR APPROVAL-----------_.._----_·..•... •••
IT IS THE PROGRA M COORDINA TOR 'S RESPONSIBILITY
TO NO TlFY THE DEGREE CANDIDA TE OF ANY DEFICIENCIES
D [ certify that this degree candidate is cleared for graduation . A completed checksheet must accompany the application.
Program Coordinator:,_ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ ____ DATE:_ _ _ _ _ _ __ _ _ __
Approved for Degree Granting: _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ __ __
Dean of Graduate Studies & Research
DATE:_ _ _ __ __ _ _
See other side
Rev 10108