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GRADUATE STUDENT INFORMATION SHEET
Name:_____________________________________ Date:___________________
ID#:____________________
Current Address:________________________________________________________
___________________________________________ Zip:____________________
Telephone:____________________________________________________________
Faculty Mentor:_________________________________________________________
Office (building and room number):__________________________________________
E-mail Address:_________________________________________________________
Individual to contact in the event of an emergency:
Name:________________________________ Relationship:___________________
Telephone:_______________ or: ___________________________________________
Address:_______________________________________________________________
_____________________________________________________________________
I have read and understand the policy regarding Workers’ Compensation.
________________________________________
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