Revised: March 19, 2018
1. A copy of a valid IL Drivers License or State ID reflecting current address must accompany this request (requests
without required copy will not be processed). Social security cards/credit cards are not acceptable identification.
2. At least 30 days prior to the start of the academic term for which you request enrollment, complete this form and
email to: or; fax to 847-214-7226 or mail to the Dean of Students Office-
B105, Elgin Community College, 1700 Spartan Drive, Elgin, IL 60123. Please allow (2) weeks for processing.
Email address: ______________________________ Social Security last 4 digits: _____ ___ ______
Name: (Last, First, Middle): _______________ _______ _______________________
Address: ______________________________________________________________
City, State, Zip: __________________ __________ ________________ Phone Num: _____ ___ ____
College I want to attend is: _____________________________________
Name of Program: _______________________________________________________
Please provide exact title from the college catalog
Type of Program: Associate in Applied Science (AAS) Degree Certificate
Approval cannot be given for AA, AS, AES Degrees
Check One: 1
Time Request Renewal
Check One: Mail authorization to me Hold authorization for pick up
Semester I will attend: Summer ____ Fall ____ Spring ____
I understand that this program is not being offered at Elgin Community College. I further understand that Joint Agreement
Authorization from Community College District 509 will be granted only for those programs (not individual courses, pre
requisites or under 100 level courses) which are not offered by Elgin Community College. Should I fail to enroll in the
above mentioned program, I shall assume all responsibility for tuition and fee expense incurred in my enrollment at the
other institution. I hereby understand that the above school will permit me to study in the program that I have requested
at their in-district tuition provided that I stay within the guidelines of the program. Deviation from the program will result
in my paying out-of-district tuition rates. My signature indicates that I understand this agreement is for the program
specified above and not for individual courses, pre requisites or under 100 level courses. I also understand that that I am
not officially accepted into a program (special admission requirements, ex Health Profession programs) until I receive
official notification from the other institution (letter of acceptance is required). I further certify that the information
contained in the notification is true and correct.
(Handwritten signature required)
Signature: ____________________________________ Date: _____________________________
For Office Use Only: Term: Summer 20 ____ Fall 20 ____ Spring 20____
Approved Yes No If not-reason ________________________ Date: ____________
Residency Verified Initials ________