Consortium Registration Form
Today’s date: Semester/Year:
DO YOU EXPECT TO GRADUATE
AT THE END OF THE TERM?
☐Yes ☐No
☐M ☐F
Gender Last Name First Name
Middle Initial
ID Number
Date of Birth Daytime phone # Email address Major
Special Services Required? ☐ Yes | ☐ No
LEVEL
☐
Undergraduate
☐ Freshman | ☐ Sophomore | ☐ Junior | ☐ Senior
☐
Graduate
☐ Masters | ☐ Doctorate
☐
Law
Home institution:
☐
American University
☐
Catholic University
☐
Gallaudet University
George Mason University
☐
George Washington University
☐
Georgetown U
niversity
☐
Howard University
☐
Marymount University
☐
Montgomery College
☐
Natl. Defense Intel. College
☐
Northern VA Community College
☐
National Defense University
☐
Prince George’s Comm. College
☐
Trinity University
☐
University of DC
☐
UMD – College Park
☐
Uniformed Services Univ. of the Health Sciences
Dept. & Course #
“Session”
Section No. Course Title
Semester
Hours
Level of Credit
Not valid for identification without
Consortium Stamp and initial
☐ Undergrad
☐ Graduate
☐ Undergrad
☐ Graduate
☐ Undergrad
☐ Graduate
Visited Institution:
☐
American University
☐
Catholic University
☐
Gallaudet University
☐
George Mason University
☐
George Washington University
☐
Georgetown University
☐
Howard University
☐
Marymount University
☐
Montgomery College
☐
Natl. Defense Intel. College
☐
Northern VA Community College
☐
National Defense University
☐
Prince George’s Comm. College
☐
Trinity University
☐
University of DC
☐
UMD – College Park
☐
Uniformed Services Univ. of the Health Sciences
Administrative Approva
Registrar / Coordinator (signature) Date Chairperson/Advisor (Signature) Date
Student
Signature Date Dean (Signature) Date
INTRUCTIONS FOR THE STUDENT
1. Complete all data items on this form, copying full course data from the appropriate Schedule of Classes.
2. Check
“level of Credit” to indicate whether course credit is to be applied to an undergraduate or graduate level at the visited institution.
3. Obtain academic and administrative approvals as prescribed by home institution.
4. Complete home institution’s registration or change of registration procedure.
5. Receive and retain a copy of this form with initialed consortium stamp for use to obtain an ID card for library purposes and to display to
instru
ctor at the first class meet
ing.
INSTRUCTIONS FOR THE INSTRUCTOR AT THE VISITED INSTITUTION
1. Have student present Consortium Registration Form bearing initialed consortium stamp to verify authorization to enter specific class.
2. Enter student’s name and home institution on your class roster. Student’s name will appear on a class roster issued later by the Registrar’s
Office of your institution
.
