FACES Fellows - Clearance Form

SPRING 2010

STEP 1: Note the date that the following form(s) were completed on the website

STEP 2: Complete Information Below:

GTID             

FIRST NAME       LAST NAME

SCHOOL              SEMESTER/YEAR       

EMAIL           

LOCAL STREET ADDRESS

CITY   STATE   ZIP

HOME NUMBER   MOBILE NUMBER

STEP 3: Verification

My submission verifies that I have met the conditions required to receive stipend payment for the
current semester. I have submitted all requested forms. If applicable, I have submitted summaries
for any missed seminars by the designated deadline.

STUDENT INTITALS