DVC AND VP (RESEARCH AND DEVELOPMENT)

MASTER OF RESEARCH GRADUATE RESEARCH SCHOOL

APPLICATION TO VARY SUPERVISOR/S LOCKED BAG 1797, PENRITH NSW 2751

Please complete this form in BLACK INK using CAPITAL LETTERS.

Master of Research students are required to provide details of a Western Sydney University academic staff member who
has agreed to act as their academic supervisor for the duration of the first year of study.

There may be instances where, for various reasons, the academic supervisor may change throughout the year.
The Master of Research Application to Vary Supervisor/s form is used to record mentorship changes in these instances.

1 - PERSONAL DETAILS
Student ID number

Title Family name

Given name(s)

2 - SUPERVISOR DETAILS
Current Supervisor/s School/Institute Signature
SUPERVISOR NAME SCHOOL/INSTITUTE SIGN HERE
SUPERVISOR NAME SCHOOL/INSTITUTE SIGN HERE
New Supervisor/s School/Institute Signature
SUPERVISOR NAME SCHOOL/INSTITUTE SIGN HERE
SUPERVISOR NAME SCHOOL/INSTITUTE SIGN HERE
3 - REASON
Please indicate a reason for the change

4 - SIGNATURES
Signature of student Date
SIGN HERE D D / M M / Y Y Y Y

Name of HDR Director / Delegate Signature of HDR Director / Delegate Date

NAME SIGN HERE D D / M M / Y Y Y Y

If the change of supervisor/s results in a change of School/Institute, please complete the below:
Name of previous HDR Director / Delegate Signature of previous HDR Director / Delegate Date

NAME SIGN HERE D D / M M / Y Y Y Y

Please return this form to grs.mres@westernsydney.edu.au

In providing my personal information to the University, I understand that, other than as authorised by law, the University will only use this information for the purposes for which it is being collected in accordance with the University’s
functions and activities associated with my enrolment. In some instances, the University may need to disclose information to any Government department which administers or has authority regarding education or immigration policy and
law and any other Government agencies (State, Territory or Federal, an affiliated entity of the University, or to third parties for the purposes of recovering unpaid University fees or other debts owed to the University, and I consent to such
disclosure. I also understand that all information will be collected, stored, accessed and disseminated or destroyed in accordance with privacy, records management and other relevant laws, and the University’s policies.

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