INTERNATIONAL HUMAN RIGHTS CERTIFICATE

							                         INTERNATIONAL HUMAN RIGHTS CERTIFICATE
                                            Special Application Form


I request approval for (Check One):

______ A senior project/capstone in the major with a human rights focus.
______ Study abroad credit
______ Honors Special Topics course
______ Internship or service learning project

Name _________________________________                          Major ______________________________
Phone _________________________________                         Email ______________________________
Street Address ________________________________________________________________
City/State ____________________________________________                             Zip ________________
Cumulative GPA _________                               Expected Month/Year of Graduation ________


COMPLETE ALL RELEVANT SECTIONS BELOW
Faculty/instructor of class or project -- attach course syllabus. Letters of support welcome.
Name _________________________________________                              Department ______________
Phone ____________________________                            email________________________________
Course Title, description : ______________________________________________________
_____________________________________________________________________________
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If applying for intern credit indicate prior credits earned for Individual Work/Internships _____
         Describe below and/or on a printed attachment with supporting documents the basis for your application
and how it is appropriate for credit toward the human rights certificate.

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12/21/2004