Name:
Last First Middle
Student ID No. Home Institution:
Telephone No.:
E-mail Address:
Sex:
Current Address:
Box City ZipStateStreet
Female Male
Race/Ethnicity:
Which term and year do you wish to enroll:
Total hours registered at home institution for current term:
[excluding consortium course(s)]
Academic Major:
Have you ever attended the host institution? Yes No If yes, list dates:
Dean or Authorized Office
(If required by Home Institution)
Date
Registration Office Home Institution
Certifies full-time
Registration Office Host Institution
Certified Registration
Date
Date
Host Course No. Section Course Title Day Time Credit Hours
SAMPLE
ACCT 2121 001 Principles of Accounting 1 M-W-F 4 pm 3
1.
2.
Alternate
Alternate
Citizenship Data:
US Citizenship
Non-citizen
Refugee
Non-Immigrant/Non-Resident Alien
Non-Immigrant Visa Type: (Select One)
B1 B2 F1 H1 J1 Other (OV)
Country of Citizenship
Permanent Resident Alien
Resident Alien Card Number:
Issue Date:
Expiration Date:
Home Institution: Host Institution:
Date of Birth:
Greater Charlotte Consortium
(Applicable to full-time, undergraduate, degree-seeking students only)
Where I'm currently enrolled. Where I want to take class(es).
INSTRUCTIONS TO THE STUDENT
1. After obtaining advisor's signature on the completed form, present it to the Registrar's Office of your Home Institution for proper signature(s).
INSTRUCTIONS FOR THE HOME REGISTRAR
1. Verify student's eligibility; that student is full time at your institution.
2. Designated official: Submit completed form to Host institution Registrar by email or fax.
INSTRUCTIONS FOR THE HOST REGISTRAR
1. At the conclusion of the term, an official transcript will be sent from the Host institution to the Home institution.
Registration complete? Yes No
Student ID No. Host Institution:
If previously attended
Yes No
Registered for
Course
Advisor
(If required by Home Institution)
Student Signature Date
Date
