Georgetown University Medical Center
Interdisciplinary Program in Neuroscience
Thesis Committee Proposal

This form should be filled out and submitted during the summer after your second year.
Note:  The thesis mentor is NOT a member of this committee
           There must be at least FOUR members of the committee
           At least one member must be from outside Georgetown
           At least two members must be members of the IPN 

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Name of student:
e-mail:
Name of thesis mentor:
e-mail:

First Proposed member of the Thesis Adisory Committee:

Position and affiliation of this proposed member:

Second Proposed member of the Thesis Adisory Committee:

Position and affiliation of this proposed member:

Third Proposed member of the Thesis Adisory Committee:

Position and affiliation of this proposed member:

Fourth Proposed member of the Thesis Adisory Committee:

Position and affiliation of this proposed member:

Other Proposed member of the Thesis Adisory Committee:

Position and affiliation of this proposed member:

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        This form will be sent to the Chair of the SAC, Director of the IPN, and the Administrator of the IPN