School of Nursing Clearance Form

*Mandatory field

General Information

*Full Name

*Program
BSN MSN PhD DNP Post-Masters

*Student ID#

Academic Information

*Graduate Students – Title of Eval and Appl of Research Paper, Thesis, or Dissertation

Undergraduate Students – Title of Honors Project and Name

Name of Honors Faculty Mentor

Contact Information

*Non-UT Email

*Current Address

*Home Phone

Cell or Other Phone

*Diploma Address (Location were you wish to have your diploma mailed)

Employment Information

*Are you currently employed?
Yes No

If yes where are you working?

If yes, what is your job title?

*Where will you be working AFTER graduation?

*What will be your job?

*Is the facility in which are working or plan to work in a medically underserved community?
Yes No

If Yes, name and location of Facility

UT Locker

*I release my UT Locker
Yes No NA

*I plan to be enrolled next term and would like to retain my UT Locker after graduation.
Yes No

University of Texas School of Nursing at Houston
6901 Bertner
Houston, TX 77030