GS Dissertation Advisor / MTA Declaration Header Image

Dissertation Advisor / MTA Declaration Form

Student Information

Student Name*
Date of Matriculation*
Degree*
I expect to receive a PhD in (Please select one)*
I agree to fulfill the requirements of the proposed training area.*
Dissertation Advisor Name*
Dissertation Advisor Name #2
Dissertation Advisor Name #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.

To be completed by the Dissertation Advisor

Dissertation Advisor*

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

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.

(If your approver is not listed, email gs-admin@mssm.edu to have them added.)
Department Administrator Name
Use your mouse or finger to draw your signature above

To be completed by the Dissertation Co-Advisor

Dissertation Advisor

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

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?
(If your approver is not listed, email gs-admin@mssm.edu to have them added.)
Department Administrator Name
Use your mouse or finger to draw your signature above

Department Approval

Department Administrator Name*
Use your mouse or finger to draw your signature above

Department Approval 2

Department Administrator Name*
Use your mouse or finger to draw your signature above