3050 Martin Luther King, Jr. Drive Phone: (318) 670-9229
Shreveport, Louisiana 71107 FAX: (318) 670-6344
To be completed by Student:
Application for Course Registration: Fall Spring Summer Year ________
NOTE: Students are required to attach a copy of the paid receipt for the semester.
Name: _____________________________________________________ Banner ID Number: 9000
Last First Middle
Mailing Address: __________________________________________________________________________
Street Address City ST Zip
Home Number: Mobile Number:
Last 4-digits of Social Security Number: xxx-xx- Date of Birth:
Have you previously attended Southern University at Shreveport? Yes No
Have you previously attended Louisiana State University Shreveport? Yes No
__________________________________________ _____________________
Student’s Signature Date
NOTE: Students taking at least 12 non-developmental hours per semester (including summer) at Louisiana State University at Shreveport may be
eligible for a tuition and certain fees exemption* for up to three hours per semester. Contact the Registrar’s Office in the Leonard C. Barnes
Administration Building, Room A-02, for more information. A current list of fees that are exempt is available in the Finance and Administration
To be completed by Student’s Advisor:
Course Prefix/Number: __________ Course Title: ________________________________ Credit hr (s):____
Alternate Course:
Course Prefix/Number: __________ Course Title: ________________________________ Credit hr (s):____
Advisor’s Name: _________________________________ Department: _________________________
Advisor’s Signature: ____________________________________________ Date: ___________________
To be completed by the Registrar:
The above student is enrolled full-time at:
Southern University at Shreveport Louisiana State University Shreveport
I have verified that fees are paid in full for the current semester.
Registrar’s Signature Date
Registrar’s Office
Inter-Institutional Cooperative Program
Authorization Form
RO: Inter-Institutional Cooperative Program Authorization:08/15:TJ
Institution’s Seal