Request For Expedited Cooperative Admission For Students Participating In Cooperative Graduate Degree Programs Form

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University of Alabama

University of Alabama at Birmingham

University of Alabama in Huntsville

REQUEST FOR EXPEDITED COOPERATIVE ADMISSION

FOR STUDENTS PARTICIPATING IN

COOPERATIVE GRADUATE DEGREE PROGRAMS

Student Name______________________________________________ Home Campus Student # _____________

Blazer ID ___________________

Last

First

Address_______________________________________________________________________________________

Street

City

State

Zip

Citizenship Status: ( ) U.S. citizen

( ) Immigrant, Permanent Resident

( ) Non Immigrant Visa (specify) ________________________

Residency: Is Alabama your permanent, legal state of residence? ( ) Yes ( ) No

Telephone:__________________________

Email:________________________________

Home Institution:

_____UA _____UAB

_____UAH

Graduate Degree Program:______________________________

Full or Part Time:___________

Entrance Date:_______________________________________

Graduate GPA:_____________

Semester

Year

Course numbers, titles, and credits in which you will be concurrently enrolled at home institution while taking courses at the other

institution_____________________________________________________________________

Proposed Cooperative Institution:

_____UA _____UAB

_____UAH

Proposed entrance date: __________________________________________________________

Semester

Year

Proposed courses, title, and credits in which you wish to enroll at the cooperative institution:

______________________________________________________________________________

I certify that the information provided above is correct and complete:

_____________________________________________________

___________________

Student Signature

Date

I approve the proposed courses listed above:

_____________________________________________________

___________________

Advisor

Date

I certify that the student is admitted to a cooperative graduate degree program and is in good standing at the home institution:

_____________________________________________________

___________________

Graduate Dean, Home Institution

Date

Approved for cooperative admission:

_____________________________________________________

___________________

Graduate Dean, Host Institution

Date

------------------------------------------------------------------------------------------------------------------------------------------------------------

If the student is an international student subject to SEVIS reporting requirements (e.g. F-1, J-1 visa) then the following section should be

completed.

Based on the course enrollment information on this form, I certify that the above-named student will be in compliance with SEVIS

requirements for the semester indicated. A record noting concurrent enrollment has been made in the student’s SEVIS record.

_________________________________________________

____________________

DSO, Home Institution

Date