Prince George’s County Public Schools
Dual Enrollment Form
Name
PGCPS Student ID Number
High School
Grade in School
Counselor’s Name
Academic Semester
(Fall, Spring, Summer) Year Cumulative GPA
!
I am aware that I must meet college requirements for dual enrollment before I am admitted to the
college. Additionally, I agree to allow the college or university to share information regarding my
academic record with Prince Georges County Public Schools (PGCPS) until I graduate or am no longer
a registered PGCPS student.
!
I am aware that I must provide my own transportation.
!
I understand that while a dual credit student, I am to abide by both the PGCPS and the college or
university student codes of conduct.
!
I understand that I am responsible for paying the cost of textbooks and applicable fees. Students who
receive free and reduced meals (FARMS) will have textbooks and fees paid by PGCPS.
Student
Signature
Da
t
e
Parent/Guardian
Signature
Da
t
e
Approved
Course(s): (Please indicate if the course is being taught at a PGCPS School)
!
The
above
student is certified to be in the 11
th
or 12
th
grade on the first day of the college course or is a rising
11
th
or 12
th
grader during summer session; a
registered PGCPS
student; and has a
cumulative grade
poin
t
average
of at least a 2.5.
Counselor’s Signature
Date
Principal’s Signature
Da
t
e
Application for Dual Enrollment Admission
Continuing Education and External Programs
Thurgood Marshall Library, Room 1128
14000 Jericho Park Road
Bowie, Maryland 20715-9465
Phone: 301-860-3991 Fax: 301-860-4081
BSU Cashier: 301-860-3495
Email:ContinuingEd@bowiestate.edu
Dual Enrollment Students are not eligible to receive Financial Aid
Please Print Information Clearly
Non-refundable Application Fee $17.00 - Payment of Fees For Classes Is Due At The Time Of Registration.
Semester
Year
Section I: General Information
Social Security Number: BSU Student Identification Number:
Name:
Last First M.I. Maiden/Former Name
Current Address:
-
Street City State Zip County - Country
Please check and sign if you want to change the address BSU currently has on file. Signature:
Work/Daytime Telephone: Home/Evening Telephone:
Cell Phone Number:
Email Address:
Section II: Personal Information
The University is required by Federal, state and local governments to supply admission and enrollment information. This information
is not used as a factor in determining eligibility for admissions.
Birth Date: / / Gender: Female
Male
Please answer both questions regarding race/ethnicity:
1.
Are you of Hispanic or Latino origin? Yes No
2.
What is your race? Select one or more of the following categories, as appropriate.
White American Indian or Alaska Native Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American: A person having origins in any of the black racial groups of Africa.
Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example,
Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central
America) who maintains cultural identification through tribal affiliation or community attachment.
Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific
Islands.
National Origin (Check only one):
United State Citizen: Non-United States Citizen, please complete the following: _ _
Country of Citizenship: Type of U.S. Visa:
Sponsored by: If permanent resident, U.S. alien registration number:
Date of Issuance:
(A photocopy of the front and back of your permanent resident card is required)
Person to contact in case of an emergency:
Name:
Telephone: Relationship to Applicant:
Education
High School Diploma-Date
GEDDate:
Bachelor’s Degree Date
Are you currently enrolled in a degree program at another College/University? Yes No If yes, where:
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Registration Form
LIST YOUR DESIRED COURSES BELOW. ACCURACY IS ABSOLUTELY NECESSARY. IT IS YOUR
RESPONSBILITY TO LIST ALL INFORMATION CLEARLY.
YOU MUST HAVE A BACHELOR’S DEGREE TO TAKE GRADUATE COURSES.
Subject
Section
Course
Number
Description
Hrs
Day
Time
ANTH
001
2592
Intro to Anthropology
3
TR
9:30 – 10:30
PAYMENT OF FEES FOR CLASSES ARE
DUE AT THE TIME OF REGISTRATION.
CHECK THE OFFICIAL ROSTER FOR YOUR ENROLLMENT IN THE CLASS.
RESIDENCY INFORMATION
Do you wish to be co
nsidered for in-state tuition status? Yes No (If yes, you must complete this section of the
application.)
IF ANY OF THE CATEGORIES BELOW APPLY, PLEASE CHECK THE APPROPRIATE BOX, PROVIDE REQUESTED
INFORMATION AND/OR DOCUMENT, AND GO TO ITEM 10.
I am a part-time (50%) or full-time regular employee of the University System of Maryland or, I am the spouse of, or am
financially dependent upon a parent or legal guardian who is, a regular employee of the University System of Maryland.
Please indicate relationship:
Please attach a letter of verification from the Human Resources Office of the campus at which you or your spouse or parent or legal
guardian is employed.
___ I am a full-time active member of the U.S. Armed
Forces whose home of residency is Maryland or one who resides or is
stationed in Maryland, or the spouse or a financially dependent child of such a person. Please attach a copy of your deed or lease
(if applicable), or verification from the service that you have declared Maryland as your "home of residency" (if applicable); and the
most
recent assignment orders. Also, please indicate date of expected separation from the military _.
___ I am the spouse or child of a veteran of the United State Armed Forces using educational benefits under the Post-9/11 GI Bill
(38 U.S.C.§ 3311(b)(9) or 3319) and living in Maryland. Please submit a copy of the veteran’s DD214 and a copy of your Certificate
of Eligibility.
___ I am a veteran of the U.S. Armed Forces resident in Maryland or I am the spouse or child of a veteran of the U.S. Armed
Forces using educational benefits under 38 U.S.C. 3311 (b)(9) or 3319 and living in Maryland. (Submit a copy of the DD-214 and
an official certification of eligibility.)
Please indicate the location of the course selected:
Bowie State University campus
A PGCPS School (please specify) ___________________________________
Are you a participant in the Free and Reduced Meals (FARMs) program: ___ Yes ____ No
APPLICANTS SEEKING IN-STATE STATUS AS A MARYLAND RESIDENT MUST COMPLETE THE FOLLOWING
QUESTIONS. Failure to
complete all of the required items may result in a non-Maryland resident classification and out-of-state
charges being applied.
Residency classification information is evaluated in accordance with the University System of Maryland
policy on residency.
The applicant may be contacted for clarification of an item, or for additional information as necessary.
PLEASE CHECK ONE:
I am financially independent. I have earned taxable income and I have not been claimed as a dependent on another person's most
recent income tax returns.
I am financially dependent on another
person who has claimed me as a dependent on his/her most recent income tax returns,
or I
am a ward of the State of Maryland. If a ward of the State, please submit documentation and go to item 10.
Name of person upon whom dependent and relationship to applicant:
a.
How long have you been dependent upon this person?
b.
Is the person a resident of Maryland? Yes No
c.
Address of this person:
d.
Has this person filed a Maryland state income tax return for the most recent year on all earned taxable income? Yes No
i.
If a Maryland tax return has not been filed within the last 12 months, state reason(s):
e.
Signature of this person:
The Student Applicant is responsible for completing items 1 - 10.
1. Permanent address:
Length of time at permanent address years months
If less than 12 months, provide previous address:
Length of time at previous address years months
2. Did you move to Maryland primarily to attend an educational institution?
Yes No
3. Are all, or substantially all of your possessions in Maryland?
Yes No
4.
Do you possess a valid driver's license?
a.
If yes, initial date of issue b. In what state?
c. Most recent date of issue d. In what state?
Yes No
5.
Do you own any motor vehicles?
a.
If yes, initial date of registration? b. In what state?
b.
Most recent date of registration d. In what state?
Yes No
6.
Are you registered to vote?
a.
If yes, in what state? b. Date of registration:
c. Were you previously registered to vote in another state?
Yes No
7.
Have you filed a Maryland state income tax return for the most recent year?
Yes No
b.
If you did not file a tax return in Maryland within the last 12 months, state reason(s):
8. Is Maryland state income tax currently being withheld from your pay? If no, provide
explanation.
_
__________________________________________________________________________________
Yes No
9.
Do you receive any public assistance from a state or local agency other than one in Maryland?
a.
If yes, please
explain_
Yes No
I certify that the information provided is complete and correct. I understand that the University reserves the right to request additional
information if necessary. In the event the University discovers that false or misleading information has been provided, the Student
Applicant may be billed by the University retroactively to recover the difference between in-state and out-of-state tuition for the current
and subsequent semesters.
10. Applicant’s Signature:
Date:
PAYMENT OF FEES FOR CLASSES ARE DUE AT THE TIME OF
REGISTRATION.
CHECK THE OFFICIAL ROSTER FOR YOUR ENROLLMENT ON THE FIRST DAY OF CLASS
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signature
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