Registration Form

Note: Please print out this form and either mail or fax it to MWDD. We cannot accept electronic registration, as your signature must appear on this form to allow this information to be released.

Name: ________________________________________________________________ 

Ethnicity/Citizenship:______________________/_________________________ 

E-mail Address: ______________________________________________________ 

Local Address: 

________________________________________________________
(Street address and/or P. O.Box) 

______________________________________________________
(City, State, Zip Code, Country) 

______________________________________________________
(Telephone - including area code) 

Permanent Address: 

________________________________________________________
(Street address and/or P. O.Box) 

______________________________________________________
(City, State, Zip Code, Country) 

______________________________________________________
(Telephone - including area code) 

Degree-Granting Institution: 

______________________________________________________


Advisor: ______________________________________________________


School and/or Department:______________________________________________________


Completion Date/Degree:______________________/_________________________ 

Specialization(s): 

______________________________________________________


______________________________________________________


______________________________________________________


______________________________________________________


______________________________________________________




(Proposed) Dissertation/Thesis: 

______________________________________________________


______________________________________________________


______________________________________________________


______________________________________________________


______________________________________________________

Disseration/Thesis URL: 

__________________________________________________________________________ 

CV/Resume/Portfolio URL: 

__________________________________________________________________________ 

(If you have already received your degree and would like to have your current employment, postdoctoral or teaching position listed, you may write that information on the back of this form. This information must be in addition to that requested above.) 

I give my permission to include the above information in the Minority & Women Doctoral Directory: 

Signature ______________________________________________________


Date ______________________________________________________

You may either fax this form to:

 415-332-4799

 or mail it at the following address:

MWDD

3001 Bridgeway

Suite K119

Sausalito, California 94965