Full Name _____________________________________ SID#________________
Local Address _______________________________________________________
City ___________________________ State _______________ Zip _________
Phone ________________________________ E-mail ______________________
Permanent Address ___________________________________________________
City ___________________________ State ______________ Zip ___________
Major ______________________________ Classification ____________________
Participant Agreement
By signing this form I consent for UNC Charlotte to release all university records relating to my enrollment, attendance, courses, course grades, and other academic assessment to PRODUCE staff members. Staff members can use this information in assisting with academic advisement, and recommendations and referrals for research, graduate school, internship, co-op and permanent employment opportunities.
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Student Name: (Print) _________________________________ Signature: ___________________________________________ Date: ___________________ |
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PRODUCE Participant Application .Copyright © 1999 [Academic Initiatives For Mentoring Students]. All rights reserved. Revised: September 28, 2004 |
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