GRADUATE PROGRAM
C
HANGE REQUEST FORM
_____________________________________________________ ___________________________
Last Name First Name Middle Last four of SSN or Student ID #
_____________________________________________________ ___________________________
Address Home Phone
_____________________________________________________ ___________________________
City State Zip Work Phone
______________________ _______________________ ___________________________
Undergraduate Degree Held Teacher Certification Held Cell Phone
_____________________ _________________________ ______________________________________________
# Credit Hours Completed Anticipated Completion Term Email
__
________________________________________________ ______________________________________________
Current Program New Program Request
Please list reason for requesting program change below.
Note: certain program changes may require reapplication and/or prerequisite coursework evaluation.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_____________________________________________________
Student Signature Date
OFFICE USE ONLY
Academic Program Authorization
New Program Director
Approved Not Approved
Signature/Date
New Advisor
Approved Not Approved
Signature/Date
Dept. Chairperson (if applicable)
Approved Not Approved
Signature/Date
Student has been provided with advisement for new program: Yes No
Comments or additional requirements:
_______________________________________________________________________________________
Prior courses accepted toward new program: ____________________________________________________________________
Prior courses NOT accepted toward new program: _______________________________________________________________
Office of the Registrar Authorization
Approved Not Approved ___________________________________________________________________
Signature, Vice President for Academic Affairs or appropriate designee
Prerequisite evaluation required
Change requires reapplication
Term
Effective: _____________ Advisor Assigned:______________________ New Program Code:______________________
Processed by:______________ Date Processed: ______________ Notified (if applicable): Field Placement: Certification:
Student Copy New Advisor Copy Office Copy Former Advisor Copy
Meet with program director then return completed form to the Registrar’s Office
Located in Smyth Hall, Room 1
