GRADUATE STUDENT
T
UTORIAL AUTHORIZATION FORM
Student Information
___________________________ _____________________________________________________
Last Name First Name Middle Student ID # or SSN
___________________________ __________ ___________________________________________
Address Home Phone
___________________________ _____________________________________________________
City State Zip Work Phone
_____________________________________________________ ___________________________
Email Cell Phone
___________________________ _____________________________________________________
Program Anticipated Completion Date Advisor
Reason for Request
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Faculty Authorization*
*Note: Please attach a current syllabus with noted modification for this tutorial
Term Summer A Summer B Fall Spring 20_____
Course (prefix, number, & title) ___________________________________________________________
# of Planned Meetings w/ StudentRecommended Teaching CreditsStudent Credits______ ________ _______
Instructor _________________________________________ _____________________________
Name Signature
Program
Director ____________________________________ __________________________________
Name Signature
Chairperson ____________________________________ __________________________________
Name Signature
Dean ____________________________________ __________________________________
Name Signature
Registrar’s Office Action
Registration Completed ______________________________ _______________________________
Date Signature
