| PERSONAL INFORMATION |
| *Last
Name |
|
| *First
Names |
|
| *Your
E-mail |
|
| *Your Student ID Number |
|
| *Primary
Degree Program |
|
*Primary
Department |
If other, please specify:
|
*Enter
Academic Year you first matriculated in the current Stony Brook
primary degree program
|
|
*Previous
Institution(s):
indicate College/University, Degree, and Dates
of Attendance |
|
CONTACT INFORMATION - STONY
BROOK CAMPUS |
Campus Building |
|
| Campus
Room Number |
|
CONTACT INFORMATION - PERMANENT HOME
ADDRESS |
| Street |
|
| Apt
or Other |
|
| City |
|
| State/Province |
|
| Postal/Zip
Code |
|
| Country |
|
CONTACT INFORMATION - LOCAL HOME ADDRESS |
| Street |
|
| Apartment
or Other |
|
| City |
|
| State/Province |
|
| Postal/Zip
Code |
|
| Country |
|
| *Primary
mailing address |
* |
| *Re-enter
E-Mail |
|
CONTACT INFORMATION - TELEPHONE NUMBERS |
| Stony
Brook Office Telephone |
|
| Local Home
Telephone |
|
| Mobile
Phone |
|
| Permanent Home
Telephone |
|
| COURSES COMPLETED TO DATE |
1- Joint Art-Philosophy Seminar
Dept Number & Title (Professor[s])
Semester |
|
2- Art Course Number & Title (Professor),
Semester #1 |
|
3- Art Course Number & Title(Professor),
Semester #2 |
|
4- Philosophy Course Number &Title (Professor),
Semester #1 |
|
5- Philosophy Course Number & Title (Professor),
Semester #2 |
|
ALT- If substituting CLT or other seminar for one of above, indicate Course Number & Title (Professor),
Semester #1 |
|
| OTHER RELEVANT COURSES OUTSIDE PRIMARY DEGREE PROGRAM |
1- Additional Course Number & Title (Professor),
Semester |
|
2- Additional Course Number & Title (Professor),
Semester |
|
3- Additional Course Number & Title(Professor) ,
Semester |
|
Any additional comments
|
|
Today's Date: |
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