Office of Graduate Studies
Request to Restrict Circulation of Thesis
Last Name: _______________________ First Name: _______________________
Student ID: _______________________ Degree Program: _______________________
Department/School: _______________________
Completion of this form is required to ensure that the thesis will be held for a maximum of one year.
The Office of Graduate Studies consents only to restrictions being placed upon the availability or circulation of a
thesis prior to its deposit in the Office of Graduate Studies. Completion of this form is required and must be fully
approved and submitted to the Office of Graduate Studies before any restrictions will be applied to the
circulation of the thesis. This must be done at least one week prior to the online submission of the actual thesis.
MFA Creati
ve Writing students may request longer.
Anticipated Date of Graduation:_______________ Winter ________
_ Summer _________ Fall _________
Reason for Restriction:
Please ensure the embargo date in the electronic submission process is set. If not, the thesis will be available for
viewing.
Date of Final Exam: _____________ Date of Requested Release: _____________
Student’s Signature: _______________________________________ Date: _____________
Required Approval Signatures:
Advisor’s Name:
_______________________________________________________________________________
Advisor’s Signature: _______________________________________ Date: _____________
CoAdvisor’s Name
(ifapplicable): _________________________________________________________________
CoAdvisor’s Signatur
e: ________________________________________ Date: _____________
___________
______________________________________________________ Department Chair/ Director Name:
Department
Chair/ Director’s Signature:___________________________ Date: _____________
For the Office of Graduate Study Use Only
Date Thesis Released: ____
___________ Signature: ____
_______________________
Protection of Privacy: We are committed to protecting your privacy. Personal information is collected under the authority of the University of Guelph Act and
pursuant to the Freedom of Information and Protection of Privacy Act (FIPPA). If you have questions about the use and disclosure of your personal information,
call the Office of Graduate Studies at (519) 824-4120 ext. 56833. You can also find more information about access to information and protection of privacy at the
University of Guelph from the University Secretariat.
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