Dual Program Enrollment Form
This form is to be used by graduate students who are interested in registering for an additional
program outs
ide of their primary degree program. This form must be signed by all parties and
approved no later than the second week of the semester in which the student’s additional program
shall be completed.
First Name of Student Last Name of Student
Street Address City State Zip Code
Contact Phone Number
Student ID #
Primary Degree Program
Additional Program
*Please Note: These certificates are not eligible for financial aid unless the included courses also count as
credit towards the student’s primary degree program.
Please enter t
he term in which you anticipate completing this additional program:
Student’s Signature
Graduate School Officials Signature
Date (mm/dd/yyyy)
Year
Term
Graduate Coordinator's Signature
Date (mm/dd/yyyy)
Date (mm/dd/yyyy)
Please remit form to:
GPSinfo@southernct.edu
Select One:
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
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