CONFERENCE AUTHORIZATION
OF GRADUATE AND/OR CERTIFICATION COURSES
FIRST NAME MIDDLE LAST SOUTHERN ID
BIRTH DATE EMAIL SOCIAL SECURITY NUMBER
MAILING ADDRESS PHONE
CITY STATE ZIP CODE
CITIZENSHIP
& RESIDENCE STATUS
Please indicate the degree/emphasis you are seeking: Term you are applying for:
MSE
D CERTIFICATION Fall
Instructional Leadership Undergraduate Winter
Literacy Education Graduate Summer
Outdoor Education
Please indicate the courses you plan to take:
C
OURSE NUMBER COURSE NAME CREDITS
I understand that my conference and I assume responsibility for all financial arrangements.
S
TUDENT SIGNATURE DATE
CONFERENCE AUTHORIZATION
I authorize support for this student’s educational expenses and understand that financial arrangements are the
responsibility of the Conference and the student.
AUTHORIZING CONFERENCE OFFICIAL TITLE DATE
Please keep one copy for your records, send one copy to the student, and fax or email/scan the signed form to Ms. Mikhaile
Spence in the School of Education and Psychology.
PHONE 423.236.2496 FAX 423.236.1765 EMAIL maspence@southern.edu
click to sign
signature
click to edit
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