Application Form For Intrasystem Concurrent Enrollment
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1
2ICE
The California State University
Application for Intrasystem Concurrent Enrollment
ONLINE
(See instructions on next page)
This application is to be used by California State University students who wish to enroll concurrently at another CSU campus.
PART I.
TO BE COMPLETED BY STUDENT
(A) 1.
Home campus
2. Proposed host campus
Select Campus
Select Campus
3.
Semester/Quarter of enrollment: Home Campus
Host Campus
Fall 2013
Fall 2013
4.
Home campus student ID #
5.
Have you previously attended the proposed host campus?
Yes
No
If yes, what was the last term of attendance? (term/year)
6.
Legal name
Last
First
Middle
Maiden
7.
Social Security Number*
8. Date of birth
MM / DD / YYYY
Month
Day
Year
9.
Mailing address
Street #
City
State
Zip
10a. Home telephone # (
)
10b. Message telephone # (
)
10c. FAX # (
)
10d. E-Mail
11.
Class level at time of planned enrollment:
Freshman
Sophomore
Junior
Senior
Graduate
Postbaccalaureate
12.
Major field________________________________________
and/or credential objective________________________
13.
Are you receiving financial aid?
Yes
No
(B) Listing of course(s) planned at host campus: Care should be taken to assure that coursework completed at host campus can be used to meet home
campus requirements.
Units
Home Campus
Equivalent Requirements or
Units
Courses at Host CSU Campus
Q
S
Courses at Home CSU Campus
Q
S
Approval
Number of units planned at home campus ___________
I certify that the information I have entered above is true and that I have read and understand the eligibility requirements, enrollment conditions and
procedures as stated.
Date
Student's Signature
PART II.
TO BE COMPLETED BY HOME CAMPUS
Residence status for fee purposes:
Resident
Nonresident
Fee and/or Nonresident Payment
County of residence
Certification
International (Visa) student at time of enrollment:
No
Yes
Maximum total units approved
Fees Paid for ___________term
of___________ = $__________
REGISTRAR'S CERTIFICATION: I certify that this student's residence and Academic status are correct
(year)
according to the official records of this campus, that the student is eligible as of this date to register as a
continuing student, that the student qualifies for temporary transfer in accordance with Section 40808 or
__________________________
41030 of Title 5, that the student has complied with pertinent health-related requirements, and that this
Signature of Home Campus Official
institution approves this request for temporary enrollment for one term only.
Date
Signature
Title
Home Campus
PART III.
TO BE COMPLETED BY HOST CAMPUS
A. Approval for enrollment at host campus: Granted
Denied Date
Fee Payment/Nonresident
Tuition Certification
Remarks
Title
Signature
Fees Paid for ___________term
of ________(if any) = $_______
B.
The student registered: Date
Number of Units
Title
Signature
CSU Host Campus
*
Not used as an ID number and will not be communicated to third party.
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