Dissertation Authorization Form
It is the Department’s responsibility to pay for one archival print copy for the library. The Department may also
choose to pay to order additional print copies.
The Program Director must sign this form to authorize dissertation submittal and payment for any
orders for print copies.
The Banner Index number(s) to be charged for the copies must be provided on this form.
Submit this form to Trisha Southergill, MUS 306 or psouthergill@mtech.edu
GRADUATE STUDENT INFORMATION
LIBRARY COPY
The Graduate School will pay for one (1) library archival copy.
Banner Index Code for archival copy:
DEPARTMENT COPY/COPIES
The Graduate School will pay for one (1) copy for the program director and one (1) copy for the dissertation
advisor.
Banner Index Code for program director and dissertation advisor copies (2)
The Department will pay for the following additional department copies:
Banner Index Code for department copies:
PhD CANDIDATE COPY/COPIES
The Graduate School will pay for one (1) copy for the student.
Banner Index Code for Candidate copy (1)
The Department will pay for the following number of Candidate copies:
Banner Index Code for Candidate copies:
*If the candidate desires additional copies of the dissertation, a link will be emailed to the candidate so the candidate
can order the copies directly from the publisher.
DEPARTMENT AUTHORIZATION (Required)
Program Director Signature:
REV: 3/2/16
