Republic of the Philippines

POLYTECHNIC UNIVERSITY OF THE PHILIPPINES

Office of the Vice President for Academic Affairs
TDW Form No. 06

THESIS/DISSERTATION COMMITTEE APPOINTMENT AND ACCEPTANCE FORM

Name of Student/Candidate _________________________________ Program __________________

School Year & Semester Started in the Program ___________________________________________

Date of Passing the Comprehensive Examination __________________________________________

Thesis/Dissertation Title: ______________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Committee Name Signature (Signifying Date

Members Acceptance of
Appointment)/
Adiviser

Evaluators (2 for
a Thesis / 3 for a
Dissertation)

Recommending Approval: Approved by:

___________________________________ _____________________________
Program Chair Dean/Director