Summary: STUDENT SERVICES: ACADEMIC RECORDS & DISSERTATIONS
915 E. Washington Street 0120 Rackham Building Ann Arbor, MI 48109-1070
734-763-0171 Fax: 734-936-1809
E-mail: firstname.lastname@example.org www.rackham.umich.edu
DISSERTATION COMMITTEE FORM
Student Name: Program Name:
Academic Program Number:
Please refer to the Guidelines for Dissertation Committee Service.
When revising a Dissertation Committee, list all other members of the committee as well as the revision(s).
Action Requested: If defense date is in less than 6 months, give approximate date:
Proposed Committee Membership (PLEASE NOTE: In certain circumstances, additional documentation must be submitted with this
form. Please see the Guidelines for Dissertation Committee Service).