Please complete this form by indicating your goal as a graduate student at Eastern Illinois University and print it. Return this form to the Graduate School Office, Eastern Illinois University, 600 Lincoln Ave., Charleston, IL 61920 or fax it to: 217-581-6020. Remember that in order for you to be considered for degree candidacy, the appropriate entrance exam scores (if required) must be on file in the Graduate School Office.

Name: Social Security # or EIU E #:
Previous names (if applicable):
Street or PO Box:
City: State: Zip: Phone # :
E-Mail Address:

I was admitted in (year) to take graduate courses at EIU pursuing:

Graduate Degree

Degree:

Major:

Non-Degree (not pursuing a degree)
Teacher's Certification Only Field:

Second Bachelor's Degree

Degree:

Major:

Certificate Program: School of Technology	Certificate in Work Performance Improvement
Certificate in Computer Technology	Certificate in Quality Systems	Certificate in Technology Security

I wish to change my status to pursue:
Degree:
MA / Major:
MBA / Major: Business Administration
MS/ Major:
EDS/ Major: Educational Administration ( Specialist)
MSED/ Major:
SSP/ Major: School Psychology

Non-Degree (not pursuing a degree)
Teacher's Certification only/ Field:
Second Bachelor's Degree / Degree: Major:

Certificate Program: School of Technology	Certificate in Work Performance Improvement
Certificate in Computer Technology	Certificate in Quality Systems	Certificate in Technology Security

List completed graduate degrees at EIU (for example, MSED-Guidance & Counseling, 1992):

Effective semester for change:

Signature:___________________________________________________ Date: