800 College Avenue ~ Weed CA 96094
Phone: (530) 938-5374 ~ Fax: (530) 938-5367 ~ Email: oregon@siskiyous.edu
Last Name: First Name: MI:
Date of Birth: SSN: Phone:
Residence Address:
City: State: Zip Code:
This is my first request This is a request for renewal
I plan to begin at OIT in the: Fall Winter Spring Summer Year:
Number of degree applicable units at COS. Completed: In Progress: GPA:
How long have you resided in Siskiyou County?
Last High School attended: Dates of Attendance:
Please list two local references who can verify your residence in Siskiyou county:
Name: Phone:
Address: City: Zip Code:
Name: Phone:
Address: City: Zip Code:
I request permission to participate in the exchange program between College of the Siskiyous and Oregon Institute of
Technology. I have satisfied the eligibility requirements listed below. If granted, I am aware of the conditions of the permit
as specified below.
Student Signature: Date:
Eligibility Requirements
1. Must be a California resident.
2. Must not have any COS registration holds.
3. Must have completed one of the following sets of requirements:
a. Complete a minimum of 24 semester units of degree applicable course work from COS with an AA cumulative GPA of at least
b. Have been a Siskiyou County resident for at least one year.
Conditions of Permit
1. Issuance of this permit does not guarantee admission to Oregon Institute of Technology. A student must file a separate application
for admission to OIT and meet OIT admission requirements.
2. This permit will remain in effect if the following conditions are met:
a. Student remains in good standing at OIT;
b. Student follows prescribed course of study at OIT;
c. Exchange agreement between College of the Siskiyous and Oregon Institute off Technology remains in effect.
3. Any time spent at Oregon Institute of Technology under the auspices of this permit will not qualify toward the establishment of
residence in Oregon, i.e., it is presumed that students seeking this permit intend to retain their California residency.
Approved Disapproved
Melissa Green, Vice President, Student Services Date