Pennsylvania State System of Higher Education
Distance Education Application
Part I - To be filled out by the student
Students must type directly on this form and then print (handwritten forms can result in processing errors).
Name _________________________________________________________________ Social Security Number ___________________________
Local Address __________________________________________________________________ Date of Birth ___________________________
City ___________________________________ State ___________ Zip Code ______________ Local Phone ___________________________
Permanent Address ___________________________________________________________________ Major ___________________________
City ___________________________________ State ___________ Zip Code ______________ Current Phone ___________________________
Email Address _________________________________________
Yes _______________________________ No _________________________________ Legal PA Resident?
US Citizen? Yes No
Specify county of residence Specify country of citizenship
High School Name ________________________________________________________ Date of Graduation (GED) __________________
Address ____________________________________________________ City _______________ State ______ Zip Code _____________
Current PA State System University __________________________________________________ Cumulative GPA __________________
Dates of Attendance _____________________________________ Academic Standing (Good/Probation/Suspension) ________________
PA State System University Visiting* ________________________________________ Semester/Year to be enrolled _________________
*Affiliation agreement must be in place.
Please list course(s) you plan to take:
Office Use Only - To be completed by Academic Department
Course Equivalency
______________________________________________________________ (Your signature authorizes the release of a transcript from host institution to home institution)
Student’s Signature Date
Part II - To be filled out by officials on student's home campus. Approval attests that the student is eligible for the proposed course(s)
and the information in Part I is accurate.
Recommended Action:
Approved
Not Approved
___________________________________________________________ _________________________
Advisor/Department Chair Date
___________________________________________________________ _________________________
Dean’s Office Date
Approved
NotApproved
Acknowledged
___________________________________________________________ _________________________
Home Campus Registrar Date
Part III - To be filled out by host campus. Approval attests that the student is eligible for the proposed course(s).
Approved
Not Approved
___________________________________________________________ _________________________
Program Director Date
___________________________________________________________ _________________________
Admitting Official Date
Approved
Not Approved
Acknowledged
___________________________________________________________ _________________________
Host Campus Registrar Date
Host Campus Registrar: Please return copies of this form to home campus and student.
Updated 07/2019 page 2
Native Hawaiian or Pacific Islander
Black or African American
What is your ethnicity?
What is your race?
We are required to collect race & sex data on applicants. Therefore, you are asked to voluntarily answer the following questions: