Request To Select Thesis/Dissertation Advisor For

Request to Select Thesis/Dissertation Advisor for

Physiology Graduate Pro gram

I) Upon successful completion of all first year academic requirements, I hereby select

_____________________________ to serve as my advisor in completion of my terminal degree in

Name of A dvisor

the Physiology Graduate Program.

Petitioning Student Print Name Student Signature Date

II) I agree to serve as the advisor for the petitioning student and to provide them with financial support during their graduate studies. I also agree to serve in accordance with the Physiology program guidelines and advisor expectations and within the School of Graduate Studies guidelines.

________________________________________________________________________________

Advisor Print Name Advisor Signature Date

___________________________________________________________________

Name and Contact Information of Advisor’s Administrator

This request has been reviewed and the following action recommended:

Action: ? Approved ? Not Approved. Comments (or attach explanation):

______________________________________________

______________________________________________

Prepared by Physiology Graduate Committee on 2/14/11