Name: __________________________________________________________________

Major: __________________________________________________________________

E-mail address: __________________________________________________________

Local address: ___________________________________________________________

Academic advisor: ________________________________________________________

Cluster: _________________________________________________________________

Name of Course & Course Number Term/Yr. Instructor

1.

2.

3.

Explanation of the integrative project (100-300 words; complete on back if necessary):

Signature of the Director or Associate Director of the University Honors Program:

____________________________________________        Date: ____________

Signature of the Cluster Coordinator or Associate Dean for Connected Learning:

____________________________________________        Date: ____________