Name_______________________________________________________________________
Banner ID________________ Major_______________________ Adviser_________________
Class (circle one): Freshman Sophomore Junior Senior
Phone____________________________
E-mail ____________________________
Permanent address _____________________________________________________________
_____________________________________________________________________________
Local address __________________________________________________________________
_____________________________________________________________________________
Note possible plans/interests/courses:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
______________________________________
Signature (Student)
______________________________________
Signature (Women's Studies Director)
______________________________________
Signature (Dean)
Send more information about:
_____ Women’s Studies Minor _____ Newsletter
_____ Individual Courses _____ Special Activities
Please print this page and return to:
Women’s Studies
Stabley Library, Room 103
IUP
429 South Eleventh Street
Indiana, PA 15705-1009
