Revised September 2010
Change of Mentor or Thesis/Dissertation Committee Members
Department of Biology
Use this form to request a change of mentor and/or makeup of your thesis or dissertation committee. Leave
the first line in each section blank if you are not changing your mentor. All information on this cover sheet
(except signatures) should be completed before printing the form.
I request the following changes to my committee and understand that this is subject to approval (indicated by
signatures) by the proposed mentor and/or committee members, the Graduate Program Director, and the
Department Chair.
Student:
Printed name: ________________________ Signature: ______________________________ Date: _____________
New Committee member(s):
1. Printed name (Mentor): _____________________________ Signature: __________________________________
2. Printed name: _____________________________ Signature: __________________________________
3. Printed name: _____________________________ Signature: __________________________________
4. Printed name: _____________________________ Signature: __________________________________
5. Printed name: _____________________________ Signature: __________________________________
Committee member(s) to be replaced:
1. Printed name (Mentor): _____________________________ Signature: __________________________________
2. Printed name: _____________________________ Signature: __________________________________
3. Printed name: _____________________________ Signature: __________________________________
4. Printed name: _____________________________ Signature: __________________________________
5. Printed name: _____________________________ Signature: __________________________________
Graduate Program Director
Printed name: ________________________ Signature: ______________________________ Date: _____________
