Full Name: ___________________________________ SID#: ____________________________

Local Phone: _____________________ Email: _________________________________________

Local Address: __________________________________________________________________

                        __________________________________________________________________

Major: ____________________________ Other minor: __________________________________

List courses taken in the minor so far:
________________________        ______________________         ________________________

________________________        ______________________         ________________________

________________________        ______________________         ________________________

Anticipated Term of Graduation: _______________

Student's Signature: ______________________________________ Date: ____________________

Signature Major Adviser: __________________________________ Date: ____________________

Signature Env. Minor Coordinator ___________________________ Date: ____________________

Return to B. Lee Lindner, Physics and Astronomy Department, Science Center, Room 143