1. Name: (Required: as it appears on the web)
   
   
2. E-mail: (Required: as it appears on the web)
   
   
3. Phone number to be listed (Do not use your home phone number):
   Example (269)387-5600
   
   
4. Degree program (select one):
   Ph.D. Master's
   
   
5. Your mentor (if none = "undecided"):
   
   
6. Description of your research (300 words or less):
   
   
   
   
7. Is your picture online? Yes No (if yes, then skip to 9)
   
   
8. What would you like to do about your picture?
   I like to have you take my picture
   I have my favorite picture and I will send it to you upon request.
   
   
9. List awards and honors if you like us to post them online
   
   
   
   
10. Any comments or requests?
    
    
    
    
11. Please list URL for your personal webpage, if you have any.
    
    
    
12. In the future, Biological Sciences will take pictures of you in several occasions (while you are doing experiement or while you are teaching. You will be asked if we may take your pictures before taking your pictures.). Please agree to permit Biological Sciences to use pictures that may contain your image. Even if you agree to this statement by selecting "agree" below, you reserve right to ask Biological Sciences not to use particular pictures.
    
    Agree Disagree
    
    
13. I hereby certify that information provided above is accurate to my knowledge. By pressing the "submit" button, I give my permission to Biological Sciences to use the information above as a content of the BIOS webpage. I understand that the information I provided above may be edited. I also give permission to Biological Sciences to use my pictures.
    

Please read the following information carefully before proceeding

• You understand that all the information you provide us on this page will be disclosed on the Biological Sciences Webpage (http://www.wmich.edu).
• By completing this page and by pressing "submit" button, you agree to be listed on the Biological Sciences Webpage (http://www.wmich.edu).
• Department of Biological Sciences reserves right to edit your information provided on this page.
• By completing this page and by pressing "submit" button, you prove that you read and understand this information disclosure statement.