GEOGRAPHY: Internship Committee Appointment
The Internship Committee consists of 3 members. The chair of the committee and one
other member must be from the Department of Geography. The third member may be
from another department. All members must hold advanced degrees and/or be on the
Graduate Faculty.
Student Name:
Date:
Student ID:
Briefly describe the nature of your internship project:
Committee Member Signatures
Committee Chair & Advisor:
Print
Signature
Print
Signature
Print
Signature
2nd Reader:
Internship Supervisor:
Return form to the Director of Graduate Studies, Department of Geography
cc: Departmental File
GEOGRAPHY: Non-Thesis Committee Appointment
The Internship Committee consists of 3 members. The chair of the committee and one
other member must be from the Department of Geography. The third member may be
from another department. All members must hold advanced degrees and/or be on the
Graduate Faculty.
Student Name:
Date:
Student ID:
Briefly describe the nature of your 2 research papers:
Committee Member Signatures
Committee Chair & Advisor:
Print
Signature
Print
Signature
Print
Signature
2nd Reader:
3rd Reader:
Return form to the Director of Graduate Studies, Department of Geography
cc: Departmental File
2
GEOGRAPHY: Thesis Committee Appointment
The Internship Committee consists of 3 members. The chair of the committee and one
other member must be from the Department of Geography. The third member may be
from another department. All members must hold advanced degrees and/or be on the
Graduate Faculty.
Student Name:
Date:
Student ID:
Briefly describe the nature of your thesis:
Committee Member Signatures
Committee Chair & Advisor:
Print
Signature
Print
Signature
Print
Signature
2nd Reader:
3rd Reader:
Return form to the Director of Graduate Studies, Department of Geography
cc: Departmental File
3
RECOMMENDATION FOR
DOCTORAL ADVISORY/DISSERTATION COMMITTEE APPOINTMENT
School/Department: _____________________________________________
Date: __________________
Student’s Name: ________________________________________________
ID#: __________________
Mailing Address: ___________________________________________________________________________
Degree: ___________________
Major: ______________________________________________________
Tentative title of dissertation: _________________________________________________________________
__________________________________________________________________________________________
The following graduate faculty members are recommended to The Graduate School as doctoral
advisory/dissertation committee members for the above-named student and each one has agreed to assume this
responsibility:
Please sign below, and print name under the signature line:
Graduate Faculty Status
(Member, Assoc., Adjunct)
Chair: ______________________________________________________
________________________
Member: ______________________________________________________
________________________
Member: ______________________________________________________
________________________
Member: ______________________________________________________
________________________
Member: ______________________________________________________
________________________
Department Chair or
Director of Graduate Study: _______________________________________
Date: ___________________
Dean, School of Education: _______________________________________
(required for education majors)
Date: ___________________
Approved: _____________________________________________________
Dean of The Graduate School
Date: ___________________
Original to Student File
c:
Department Chair or Director of Graduate Study
Dean (for education majors)
Committee Chair
Student
4
GEOGRAPHY Plan of Study: GIScience Certificate
Name
Preliminary or Final Plan? (P/F)
Student ID
Total Number of Hours:
Deficiency Coursework – Undergraduate courses
required if you enter the program without the
requisite Geography background
Required Courses
Course
Semester
Taken
18
Credit
Hours
Grade
Area
GEO 520
Cultural
GEO 521
Physical
GEO 613
Regional
GEO 614
Technical
Deficient?
(y/n)
Course
Semester
Taken
Credit
Hours
GEO 620
Electives (one of the following courses – GEO 623, STA 571, CSC 570, BIO 522)
Additional courses may be approved – see the Director of Graduate Studies
Course
Semester
Taken
Credit
Hours
Grade
Director of Graduate Studies, Geography
Date
Student, Geography
Date
Return form to the Director of Graduate Studies, Department of Geography
cc: Departmental File, Graduate School
5
Grade
l
GEOGRAPHY Plan of Study: Urban & Economic Development Certificate
Name
Preliminary or Final Plan? (P/F)
Student ID
Total Number of Hours:
Deficiency Coursework – Undergraduate courses
required if you enter the program without the
requisite Geography background
Required Courses
Course
Semester
Taken
18
Credit
Hours
Grade
Area
GEO 502
Cultural
GEO 533
Physical
PSC 520
Regional
PSC 630
Technical
Deficient?
(y/n)
Course
Semester
Taken
Credit
Hours
Electives (two of the following courses – GEO 602, GEO 603, GEO 622, GEO 631, PSC 613, PSC 620)
Additional courses may be approved – see the Director of Graduate Studies
Course
Semester
Taken
Credit
Hours
Grade
Director of Graduate Studies, Geography
Date
Student, Geography
Date
Return form to the Director of Graduate Studies, Department of Geography
cc: Departmental File, Graduate School
6
Grade
DOCTORAL PLAN OF STUDY
School/Department: _____________________________________________
Date: ___________________
Student’s Name: ________________________________________________
ID#: ___________________
Degree: ___________________
Major: _____________________________________________________
This course work proposal has been approved by the following advisory/dissertation committee:
Please sign below, and print name under signature line:
Chair: ________________________________________________________
Member: ____________________________________
Member: ___________________________________
Member: ____________________________________
Member: ___________________________________
Department Chair or
Director of Graduate Study: _________________________________________
Date: ___________________
Dean, School of Education: __________________________________________ Date: ___________________
(required for education majors)
This Plan of Study is approved and will be on file in The Graduate School. Any changes that are made in this
plan must bear signatures of all individuals listed above and must be filed with The Graduate School for
approval.
When the student applies for admission to candidacy, The Graduate School will check his/her academic record
against the Plan of Study before presenting the student’s application to the Dean of The Graduate School or the
Dean’s Designee for approval.
Approved: ____________________________________________________
Dean of The Graduate School
Date: ___________________
Original to Student File
c: Department Chair or Director of Graduate Study
Dean (for education majors)
Committee Chair
Student
7
GEOGRAPHY: Dissertation Plan of Study
Name
Preliminary or Final Plan? (P/F)
Student ID
Total Hours
Required Core Courses
Course
Semester Taken
Credit Hours
Grade
GEO 620
GEO 760
GEO 761
Cluster Courses –24 hours required* (*no more than 6 credit hours of 500- level courses may be taken)
Geographic Techniques (6 credit hours)
Course
Semester
Taken
Credit
Hours
Physical Geography (6 credit hours)
Grade
Course
Urban Geography (6 credit hours)
Course
Semester
Taken
Credit
Hours
Semester
Taken
Credit
Hours
Grade
Dissertation-related Courses (6 credit hours)
Grade
Course
Semester
Taken
Credit
Hours
Grade
Dissertation (15-21 hours)
Course
Semester Taken
Credit Hours
Grade
GEO 799
Director of Graduate Studies, Geography
Date
Student, Geography
Date
Return form to the Director of Graduate Studies, Department of Geography
cc: Departmental File, Graduate School
8
DOCTORAL PLAN OF STUDY REVISION
School/Department: _____________________________________________ Date: ___________________
Student’s Name: ________________________________________________ ID#: ___________________
Degree: ______________________ Major: __________________________________________________
Please justify the following additions, deletions or substitutions to the original Plan of Study (dated _________)
that are recommended to The Graduate School:
These revisions have been approved by the following advisory/dissertation committee:
Please sign below, and print name under signature line:
Chair: ______________________________________________________
Member: ____________________________________ Member: ___________________________________
Member: ____________________________________ Member: ___________________________________
Department Chair or Director of
Graduate Study: _______________________________________________ Date: ___________________
Dean, School of Education _______________________________________ Date: ___________________
(required for education majors)
Approved:_____________________________________________________ Date: ___________________
Dean of The Graduate School
Original to Student File
c: Department Chair or Director of Graduate Study
Dean (for education majors)
Committee Chair
Student
9
GEOGRAPHY: Internship Plan of Study
33 Hours
Name
Preliminary or Final Plan? (P/F)
Student ID
Concentration in Urban
Planning?
Required Courses
Course
Semester
Taken
Deficiency Coursework – Undergraduate courses required if you
enter the program without the requisite Geography background
Credit
Hours
Grade
Area
GEO 601
Cultural
GEO 695
Physical
Deficient?
(y/n)
Course
Semester
Taken
Credit
Hours
Grade
Regional
Technical
Electives (600 level and higher) – minimum of 18
hours required, including 601 and 695
Course
Semester
Taken
Credit
Hours
Grade
Electives (500 level) – Credit hours for these courses,
when added to 600 level credits, must = 33 credit hours
Course
Semester
Taken
Credit
Hours
Grade
Collateral Expertise Coursework – 6 hours in computer science, research methods, or statistics, 200 or higher level. Coursework
from previous degree may be acceptable—see Director of Graduate Studies. These hours do not count towards your degree.
Course
Semester Taken
Student Signature
Date
Director of Graduate Studies, Geography
Date
Return form to the Director of Graduate Studies, Department of Geography
Credit Hours
Grade
cc: Departmental File, Graduate School
10
GEOGRAPHY: Non-Thesis Plan of Study
36 Hours
Name
Preliminary or Final Plan? (P/F)
Student ID
Concentration in Urban
Planning?
Deficiency Coursework – Undergraduate courses required if you enter
the program without the requisite Geography background
Required Courses
Course
Semester
Taken
Credit
Hours
Grade
GEO 601
Area
Deficient?
(y/n)
Course
Semester
Taken
Credit
Hours
Grade
Cultural
Physical
Regional
Technical
Electives (600 level and higher) – minimum of 18
hours required, including 601 and 695
Course
Semester
Taken
Credit
Hours
Grade
Electives (500 level) – Credit hours for these courses,
when added to 600 level credits, must = 33 credit hours
Course
Semester
Taken
Credit
Hours
Grade
Collateral Expertise Coursework – 6 hours in computer science, research methods, or statistics, 200 or higher level. Coursework
from previous degree may be acceptable—see Director of Graduate Studies. These hours do not count towards your degree.
Course
Semester Taken
Student Signature
Date
Director of Graduate Studies, Geography
Date
Return form to the Director of Graduate Studies, Department of Geography
Credit Hours
Grade
cc: Departmental File, Graduate School
11
GEOGRAPHY: Thesis Plan of Study
33 Hours
Name
Preliminary or Final Plan? (P/F)
Student ID
Concentration in Urban
Planning?
Required Courses
Course
Semester
Taken
Deficiency Coursework – Undergraduate courses required if you
enter the program without the requisite Geography background
Credit
Hours
Grade
Area
GEO 601
Cultural
GEO 699
Physical
Deficient?
(y/n)
Course
Semester
Taken
Credit
Hours
Grade
Regional
Technical
Electives (600 level and higher) – minimum of 18
hours required, including 601 and 695
Course
Semester
Taken
Credit
Hours
Grade
Electives (500 level) – Credit hours for these courses,
when added to 600 level credits, must = 33 credit hours
Course
Semester
Taken
Credit
Hours
Grade
Collateral Expertise Coursework – 6 hours in computer science, research methods, or statistics, 200 or higher level. Coursework
from previous degree may be acceptable—see Director of Graduate Studies. These hours do not count towards your degree.
Course
Semester Taken
Student Signature
Date
Director of Graduate Studies, Geography
Date
Return form to the Director of Graduate Studies, Department of Geography
Credit Hours
Grade
cc: Departmental File, Graduate School
12
GEOGRAPHY: Master’s Comprehensive Exam Schedule
The Master’s Comprehensive Exam Schedule is completed by the Comprehensive Exam Committee
and submitted to the Director of Graduate Studies four weeks prior to the Comprehensive Exam.
The Exam Committee consists of 3 members from the department with whom you have had
coursework.
The results of the examination are submitted in writing by the Chair of the committee to the Director
of Graduate Studies no later than four weeks following the examination.
The Master’s comprehensive examinations are scheduled once each fall and spring semester,
typically in mid-October and mid-March.
Student Name:
Date:
Student ID:
Examination Date:
Committee Member Signatures
Committee Chair:
Print
Signature
Print
Signature
Print
Signature
2nd Member:
3rd Member:
Return form to the Director of Graduate Studies, Department of Geography
cc: Departmental File
13
GEOGRAPHY: Doctoral Preliminary Comprehensive Exam Schedule
The Doctoral Preliminary Comprehensive Exam Schedule is completed by the Doctoral Dissertation
Committee and submitted to the Director of Graduate Studies four weeks prior to the
Comprehensive Exam.
The results of the examination are submitted in writing by the Chair of the committee to the Director
of Graduate Studies no later than four weeks following the examination.
The Doctoral Preliminary Comprehensive Examinations are scheduled on an individual basis during
either the Fall or Spring semesters.
Student Name:
Date:
Student ID:
Examination Date:
Committee Member Signatures
Committee Chair:
Print
Signature
Print
Signature
Print
Signature
Print
Signature
2nd Member:
3rd Member:
4th Member:
Return form to the Director of Graduate Studies, Department of Geography
cc: Departmental File
14
RESULTS OF MASTER’S COMPREHENSIVE EXAMINATION
TO:
The Graduate School
FROM: __________________________________________________________________________
(Candidate’s Committee Chair)
DEPARTMENT/SCHOOL: _________________________________________________________
DATE: ______________________
RE: Results of Written Comprehensive Examination
Degree Candidate: ______________________________________
Degree: ________________________
ID#: ____________________
Major: __________________________________________
Date of Examination: _______________________________
Competency Rating: ___________________
(Pass)
___________________
(Fail)
Comments:
15
RESULTS OF PRELIMINARY DOCTORAL COMPREHENSIVE
EXAMINATION
TO:
The Graduate School
FROM: __________________________________________________________________________
(Candidate’s Committee Chair)
DEPARTMENT/SCHOOL: _________________________________________________________
DATE: ______________________
RE: Results of Written Comprehensive Examination
Degree Candidate: ______________________________________
Degree: ________________________
ID#: ____________________
Major: __________________________________________
Date of Examination: _______________________________
Competency Rating: ___________________
(Pass)
___________________
(Fail)
Comments:
16
RESULTS OF ORAL EXAMINATION IN DEFENSE OF
THESIS/DISSERTATION
TO:
The Graduate School
FROM: __________________________________________________________________________
(Candidate’s Committee Chair)
DEPARTMENT/SCHOOL: _________________________________________________________
DATE: ______________________
RE: Results of Oral Examination in Defense of :
Thesis
Degree Candidate: ______________________________________
Degree: ________________________
Dissertation
(circle one)
ID#: ____________________
Major: __________________________________________
Date of Examination: _______________________________
Competency Rating: ___________________
(Pass)
___________________
(Fail)
Comments:
17
APPLICATION FOR ADMISSION TO CANDIDACY
(DOCTORAL CANDIDATES ONLY)
This application should not be filed until all course requirements have been completed, language requirement or
approved option has been satisfied, preliminary written and oral comprehensive examinations have been passed,
and an approved dissertation topic has been filed in The Graduate School.
DATE: __________________________________
TO:
The Dean of The Graduate School or Dean’s Designee
FROM: ______________________________________________________
Student’s Name
_______________________
ID#
On the basis of my course work to date, I respectfully petition for admission to candidacy for the degree of
________________ with a major in ___________________________________________________.
For those in degree programs requiring proficiency in a language, please indicate how this requirement has been
met (ETS Foreign Language Exam, Reading Knowledge Examination through Department of Romance
Languages or German Department, language course, etc.) and date of examination:
________________________________________________________________________________.
Mr., Mrs., Ms. _____________________________________________________________________
Signature
_____________________________________________________________________
Street
_____________________________________________________________________
City, State, Zip
THE FOLLOWING ENDORSEMENT FOR ADMISSION TO CANDIDACY MUST BE SIGNED BY
THE CHAIR OF THE STUDENT’S DOCTORAL COMMITTEE BEFORE THIS APPLICATION CAN
BE APPROVED FOR ACTION:
This student has satisfied all conditions to his/her admission, including evidence of research competency (if
required) either through the demonstration of proficiency in statistics or a foreign language.
Signed: ____________________________________________________________________________
Chair, Doctoral Advisory/Dissertation Committee
Date
*Signed: _____________________________________________________________________________
Director of Graduate Study, School of Music
Date
*Required: School of Music majors only
(Revised August 1991)
18
APPLICATION FOR GRADUATION FOR GRADUATE STUDENTS
Student ID No: __________/__________/__________ Date:__________________________________ ____
Mail or bring the application to The Graduate School, 241 Mossman Bldg, UNC at Greensboro, Greensboro, NC 27402
by the end of the first week of classes of the term in which the degree will be granted. The graduation fee ($55 for
master’s and Specialist in Education; $70 for combined M.S./Ed.S.; $60 for doctorate) will be added to your student
account. Do not send a check with this application. After the fee is posted to your account, payment should be made to the
Cashiers and Student Accounts Office, UNC at Greensboro, PO Box 26170, Greensboro, NC 27402-6170. There is no
charge for Certificate candidates.
Degree or Certificate: __________________ Major:________________________________________________________
Date you expect to graduate: ( ) December ___________ ( ) May ____________ ( ) August ___________
(year)
(year)
(year)
Name (as it should __________________________________________________________________________________
appear on diploma) (first name)
(middle name or initial if desired)
(last name)
Permanent address (to which __________________________________________________________________________
diploma will be mailed--notify
No. and Street or P.O. Box No.
if change occurs)
________________________________________________________________________
Daytime
City
State
Zip Code
Phone No: (______) ________________
Area Code
Local address (if different from________________________________________________________________________
permanent address)
No. and Street or P.O. Box No.
________________________________________________________________________
City
State
Zip Code
Student’s alternate e-mail address: ____________________________________________________________________
(Graduation information will be e-mailed only to your UNCG student e-mail address)
PLAN OF STUDY: If changes have been made to the Plan of Study, all Specialist in Education and master’s degree
candidatesmust submit a revised plan of study by the end of the third week of classes.
DEADLINE FOR THESES/DISSERTATIONS: All doctoral candidates, and master’s candidates who are preparing a
formalthesis, should be aware of the following deadlines (see the University’s Academic Calendar:
www.uncg.edu/reg/Calendar):
(1) Final oral examination in defense of doctoral dissertation. Master’s thesis candidates should check with their thesis
committee chair.
(2) Submission of one copy of thesis/dissertation with The Graduate School for approval.
(3) Submission of final two copies of thesis/dissertation with The Graduate School (binding and microfilming fees are due
at this time).
19
DEADLINES FOR GRADUATION
This application must be filed with The Graduate School by the end of the first week of classes of the term in which
the degree will be granted (www.uncg.edu/reg/Calendar). Degree and/or certificate candidates must comply with all
deadlines set forth in The Graduate School calendar. Failure to do so will delay the candidate’s graduation. These
deadlines are necessary to enable everyone involved with the candidate’s degree clearance to complete the process in an
orderly and academically sound manner. Candidates who apply for a given graduation and fail to qualify must reapply for
a later graduation. Diplomas and transcripts of students owing money to the University will be held until the account is
cleared.
REMOVAL OF INCOMPLETE GRADES
Policy concerning incomplete grades is frequently misunderstood. No grade of incomplete (I) may be carried beyond
graduation, including incompletes in courses not required for the degree. It is the student’s responsibility to ensure that a
final grade has been submitted prior to graduation. If a final grade has not been recorded by the deadline date for degree
clearance, it is the student’s responsibility to check with The Graduate School to determine his/her status. A GRADE OF I
CANNOT BE REMOVED WITH A GRADE OF W.
FORMATTING AND SUBMISSION OF DISSERTATION
The dissertation must be formatted according to the instructions provided in the Guide for the Preparation of Theses and
Dissertations. A copy of the guide can be obtained from The Graduate School or from the following University Web site:
www.uncg.edu/grs/forms/T_dguide.pdf. A signed copy of your dissertation must be submitted to The Graduate School for
approval following the final oral examination. Deadline dates for submission of the dissertation are listed on the
University’s Academic Calendar (www.uncg.edu/reg/Calendar) and in The Graduate School Bulletin under Calendar of
Events.
FORMATTING AND SUBMISSION OF THESIS
The thesis must be formatted according to the instructions provided in the Guide for the Preparation of Theses and
Dissertations. A copy of the guide can be obtained from The Graduate School or from the following University Web site:
www.uncg.edu/grs/forms/T_dguide.pdf. A copy of your thesis must be submitted to The Graduate School for approval
prior to turning in the final two copies. Deadline dates for submission of the thesis are listed on the University’s Academic
Calendar (www.uncg.edu/reg/Calendar) and in The Graduate School Bulletin under Calendar of Events.
REGISTRATION IN FINAL TERM
Thesis or dissertation students must be registered in the term in which they receive their degree. Master’s candidates who
have already registered for the maximum of 6 thesis (699) hours will enroll in departmental 801 (example: ART 801 Thesis Extension). Doctoral candidates who have already registered for the required minimum of 12 dissertation (799)
hours will enroll in departmental 802 (example: ENG 802 - Dissertation Extension). See the “Academic Regulations”
section of The Graduate School Bulletin for a complete explanation of this policy.
COMMENCEMENT
Degrees are awarded after each semester and the second summer term. A commencement ceremony is held in December
for Summer Session and Fall Semester graduates, and in May for Spring Semester graduates. Diplomas will be mailed to
the student’s permanent address as it is listed on the Application for Graduation unless a new address is provided.
SCHOOL LICENSURE APPLICATION OR UPGRADE
Students seeking professional school licensure or upgrading their licensure should contact The Teacher’s Academy, Room
319, Curry Building. Phone number 336-334-3414.
20
THESIS TOPIC APPROVAL
School/Department _________________________________________________
Date _________________
Student’s Name ____________________________________________________
ID# __________________
Degree ________________
Major __________________________________________________________
Tentative Thesis Title: __________________________________________________________________
__________________________________________________________________________________________
Purpose of the Study:
Committee Approval:
Chair: ________________________________________________________________
Members: _______________________________
______________________________________
_______________________________
______________________________________
Department Chair or
Director of Graduate Study: __________________________________________ Date: _________________
Dean, School of Education: __________________________________________ Date: _________________
(required for education majors)
c: The Graduate School
21
LEAVE OF ABSENCE APPLICATION
________________________________________________________________
(Print Full Name)
__________________________
(Student ID Number)
__________________________________________________________________________________________________
(Address)
wishes to apply for a leave of absence from the ___________________________________________degree program with
a major in ___________________________________________________.
I understand that a leave of absence does not extend the time allowed for completion of the degree.
First semester registered ________________________________________
Last semester registered ________________________________________
Semester(s) on leave
________________________________________
Semester to return
________________________________________
*On the back of this form or on an attached sheet, give an explanation of the reason for your request.
(Remember to formally withdraw from all courses the semester you are on leave.)
Signature ________________________________________________
Date _______________________________
I approve this request:
____________________________________________________
Date _____________________________
Director of Graduate Study of the Department
____________________________________________________
Date _____________________________
Dean of The Graduate School or Designee
PLEASE NOTE:
For a full explanation of the policy regarding leaves of absence, please see the Policy on Continuous Enrollment
in The Graduate School Bulletin.
22
GRADUATE STUDENT REQUEST FOR TRANSFER CREDIT
(Name of university visited)
(Student’s full name and ID number)
(Student’s local mailing address)
The above named student has requested approval to transfer credit taken during the
for the following course(s):
(semester)
Course name and number
term
(year)
Credit hours
_________________________________________________________________
_____________
_________________________________________________________________
_____________
_________________________________________________________________
_____________
*I recommend the above course(s) for transfer credit to the student’s graduate degree program at UNCG:
_________________________________________________________________
Signature of Dean, Department Head, or Director of Graduate Study
_____________
Date
_________________________________________________________________
Signature of Associate Dean of The Graduate School
_____________
Date
_____ If this block is checked, the time limit in which to complete the requirements for your degree has changed
due to this transfer of credit. Your time limit will now expire with the ____________________________.
*Final approval granted by The Graduate School upon receipt of final, official transcript.
c: Department
Student
TO THE STUDENT: Please read instructions on the back of this form
23
TO THE STUDENT:
1. Please complete this form in consultation with your major advisor, department head, or director of graduate
study.
2. Submit the completed form to the UNCG Graduate School Office (241 Mossman Bldg).
NOTE:
The regulations governing the transfer of credit are set forth in The Graduate School Bulletin. Approval to
transfer credit to a degree program is conditional upon compliance with ALL limitations stated therein.
It is the student’s responsibility to ensure in advance that courses will transfer, including making sure the
courses fall within the overall limitation on the number of hours that can be transferred.
If the student will not be registered at UNCG during the semester in which they are taking courses at another
institution for transfer credit to UNCG, the student must apply for and receive a personal leave of absence.
Applications for personal leaves of absence are available in The Graduate School Office.
It is the student’s responsibility to request that a final, official transcript be sent to The Graduate School,
241 Mossman Bldg, UNCG, Greensboro, NC 27402, upon completion of the course(s).
I have read the Policy on Continuous Enrollment and the regulations governing transfer credit in The
Graduate School Bulletin and understand that I bear sole responsibility for meeting all of the conditions stated
therein.
_____________________________________________________
Signature of student
(Revised September 2004)
24