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
MI
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

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