REQUEST TO BECOME A HISTORY MAJOR

Application Date ______________________

Please print

CUID: ________________________________ Email address: ___________________

Name: _____________________________________________

Last First MI

[ ] Freshman [ ] Sophomore [ ] Junior [ ] Senior Expected date of graduation:_____________

Field of Interest within the History Major: _____________

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Local Address:__________________________________________________________

Local Phone #:__________________________________________________________

Permanent home address: ______________________________________________

______________________________________________

Permanent home phone #: ______________________________________________

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Please check all that apply below:

[ ] Double Major with:_______________________ Other Advisor:_________________________

[ ] Triple Major with:________________________ Other Advisors:________________________

[ ] College Scholar

[ ] Independent Major

[ ] Dual Degree with:________________________

Advisor’s Name:__________________________ ______________________________________

(please print) (advisor signature) (date)

PLEASE RETURN THIS FORM TO MAGGIE IN THE HISTORY OFFICE, 450 MCGRAW 9/29/04