DECLARATION OF INTENT TO PURSUE COMBINED DEGREES

Copies of this Declaration of Intent to pursue Combined Degrees must be filed

with the Office of the University Registrar. You are not enrolled in the

combined degree program until this form is completed and signed by both

colleges and processed in the Office of the University Registrar. By signing and

filing this Declaration, you (I) acknowledge receipt of the curricular

requirements and policies and procedures of the University of Arkansas for

Medical Sciences associated with your request for dual degree enrollment.

Failure to meet the combined degree program requirements can result in failure

to meet the requirements for either degree individually.

1. Name____________________________________________________

2. Student ID number__________________________________________

3. What two degrees will you be seeking?_________________________

4. Date of enrollment in the first program:_________________________

5. Anticipated date of enrollment in second program:________________

Signature______________________________

Date__________________________________

APPROVED BY:

_________________________

_______________________________

Assistant/Associate Dean Assistant/Associate Dean

College of first program enrollment College of second program enrollment

Date_____________

________ Date___________________________

*By signing and submitting this Declaration of Intent to Pursue Combined Degrees Form, you acknowledge that you will be charged the more

expensive tuition and fees, and pay the Continuing Registration Fee and college specific fees for the second program.

**During a Leave of Absence, tuition and fees will be charged for the enrolled program.