Pennsylvania State System of Higher Education
Distance Education Application
Student Instructions
The purpose of this form is to enable you to enroll in a course at another State System University and transfer
the course credit and grade to your home University if the institutions have an affiliation agreement. This will
enable you to take advantage of courses, programs or experiences not available at your home institution,
without loss of institutional residency, eligibility for honors or athletics, or credits toward graduation. If you are
not sure if your institution has an affiliation agreement, please check with the Distance Education Office at your
To be eligible to enroll in a course at another State System University:
1. You must be a current student at your home university.
2. You must obtain advanced approval from your home University by initiating Part II of this form.
3. A copy of this completed form must be received by the Registrar of the host university by the time of
your registration.
Filling out the Form
Most of the information on this form may be on file at your home university, but to enroll in another SSHE
university, your personal information must be entered into their database from this form. This will enable you to
be admitted into that university, to enroll in classes and to receive credit and grades for that course or courses.
You may enroll for a maximum of 18 credits in a single semester or summer.
Routing of this Form
1. Fill out, sign and date this form; present it to your advisor or department chair for signature and deliver
the form to the office of the dean of your college.
2. The dean's office will review, sign and forward the form to the registrar of your university. The Dean's
or Registrar's office will fill in the portions of the form on Course Equivalency and Program Placement.
3. Your registrar will send the form to the registrar of the host university (the university from which you will
be taking the class).
4. The host university registrar will forward the form to the director/chair of the program/department and
to their office of admissions.
5. The form will be returned to the host campus registrar who will forward a copy to you and to the Registrar
of your university.
6. The student will register at the host university, but will pay tuition and fees to his/her home institution.
7. The host university's official transcript will transfer all credits from the host university to the home
university. All credits and grades accrued at the host university will be accepted in full by the home
university, and thereafter treated as home university credits and grades.
8. Each university will specify and publish the approval procedure for its own students' participation and
for students from other System universities who wish to study under this policy.
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Pennsylvania State System of Higher Education
Distance Education Application
Part I - To be filled out by the student
Students must type directly on this form and then print (handwritten forms can result in processing errors).
Name _________________________________________________________________ Social Security Number ___________________________
Local Address __________________________________________________________________ Date of Birth ___________________________
City ___________________________________ State ___________ Zip Code ______________ Local Phone ___________________________
Permanent Address ___________________________________________________________________ Major ___________________________
City ___________________________________ State ___________ Zip Code ______________ Current Phone ___________________________
Email Address _________________________________________
Yes _______________________________ No _________________________________ Legal PA Resident?
US Citizen? Yes No
Specify county of residence Specify country of citizenship
High School Name ________________________________________________________ Date of Graduation (GED) __________________
Address ____________________________________________________ City _______________ State ______ Zip Code _____________
Current PA State System University __________________________________________________ Cumulative GPA __________________
Dates of Attendance _____________________________________ Academic Standing (Good/Probation/Suspension) ________________
PA State System University Visiting* ________________________________________ Semester/Year to be enrolled _________________
*Affiliation agreement must be in place.
Please list course(s) you plan to take:
Office Use Only - To be completed by Academic Department
Course Equivalency
______________________________________________________________ (Your signature authorizes the release of a transcript from host institution to home institution)
Student’s Signature Date
Part II - To be filled out by officials on student's home campus. Approval attests that the student is eligible for the proposed course(s)
and the information in Part I is accurate.
Recommended Action:
Not Approved
___________________________________________________________ _________________________
Advisor/Department Chair Date
___________________________________________________________ _________________________
Dean’s Office Date
___________________________________________________________ _________________________
Home Campus Registrar Date
Part III - To be filled out by host campus. Approval attests that the student is eligible for the proposed course(s).
Not Approved
___________________________________________________________ _________________________
Program Director Date
___________________________________________________________ _________________________
Admitting Official Date
Not Approved
___________________________________________________________ _________________________
Host Campus Registrar Date
Host Campus Registrar: Please return copies of this form to home campus and student.
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Native Hawaiian or Pacific Islander
Am. Indian or Alaskan
Black or African American
What is your sex? Male
Not Hispanic or Latino
Hispanic or Latino
What is your ethnicity?
What is your race?
We are required to collect race & sex data on applicants. Therefore, you are asked to voluntarily answer the following questions: