GS Dissertation Advisor / MTA Declaration

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Dissertation Advisor / MTA Declaration Form

Student Information

Student Name*

First Name

Last Name

Email*

Life Number*

Date of Matriculation*

Degree*

PhD MD/PhD

I expect to receive a PhD in (Please select one)*

Biomedical Sciences Neurosciences

My grade for the Core Course is:*

Select your MTA for the PhD work:*

I agree to fulfill the requirements of the proposed training area.*

Yes

Dissertation Advisor Name*

First Name

Last Name

Dissertation Advisor Email*

Dissertation Advisor Name #2

First Name

Last Name

Suffix (optional)

Dissertation Advisor Email #2

Dissertation Advisor Name #3

First Name

Last Name

Suffix (optional)

Dissertation Advisor Email #3

By initiating this declaration form, you are indicating your continued agreement to meet the standards and expectations laid out in the Compact for PhD Students and Preceptors. A [sample version] of this compact is available for viewing, and a copy of your original, signed compact can be obtained from the PhD Program Manager upon request. Your research mentor(s) (i.e., dissertation advisor(s)) will also be advised that they are expected to uphold the expectations described for preceptors in the compact.

I agree

To be completed by the Dissertation Advisor

Dissertation Advisor*

First Name

Last Name

I have read the Compact between Research Advisor and Student and understand its content

and agree to the expectations described for preceptors therein

I understand that I will be responsible for the stipend, tuition and fees for the student during the PhD work, until the thesis is defended, with appeals possible for unexpected lapses in funds.

% Contribution

Fund Number student will be charged to:*

Financial Approver*

(If your approver is not listed, email gs-admin@mssm.edu to have them added.)

Department Administrator Name

First Name

Last Name

Department Administrator Email

Signature*

[clear]

Use your mouse or finger to draw your signature above

To be completed by the Dissertation Co-Advisor

Dissertation Advisor

First Name

Last Name

I have read the Compact between Research Advisor and Student and understand its content

and agree to the expectations described for preceptors therein

I understand that I will be responsible for the stipend, tuition and fees for the student during the PhD work, until the thesis is defended, with appeals possible for unexpected lapses in funds.

Are you funding this student?

Yes No

% Contribution

Fund Number student will be charged to:

Financial Approver

(If your approver is not listed, email gs-admin@mssm.edu to have them added.)

Department Administrator Name

First Name

Last Name

Department Administrator Email

Signature

[clear]

Use your mouse or finger to draw your signature above

Department Approval

Department Administrator Name*

First Name

Last Name

Signature*

[clear]

Use your mouse or finger to draw your signature above

Department Approval 2

Department Administrator Name*

First Name

Last Name

Signature*

[clear]

Use your mouse or finger to draw your signature above