Revised 9/19/2018
INTER-INSTITUTIONAL COOPERATIVE PROGRAM (ICP)
Louisiana Tech University/Grambling University
APPLICATION AND ENROLLMENT FORM
I will be a VISITING student at Grambling State University (Select Term):
SPRING SUMMER I SUMMER II FALL
When are you scheduled to graduate?
Student Information
Last Name:
First Name:
Middle Name:
Suffix:
CWID Number:
Social Security Number:
Sex:
Race:
Citizenship:
Marital Status:
High School Graduation Date:
E-Mail Address:
Student Address
Local Address:
City:
State:
Zip Code:
Home State:
Home Parish/County:
Home Zip Code:
Current Phone:
Cell Phone:
COLLEGE (Check One)
Applied & Natural Science
Business
Education
Engineering & Science
Liberal Arts
Under Graduate
Graduate
Major:
List courses for which you are enrolling as a visitor:
CRN
Number
Course
Number
Section
Credit
Hours
Course Description
Days
Time
Instructors Name
“… Any schedule exceeding 12 semester hours must be approved in writing by the students Dean on the registration form or the schedule change.
Courses pursued in excess of the allowed limits without approval will be invalidated upon discovery. Correspondence courses and concurrent
enrollment at other institutions are considered as part of this load and must be approved by the Dean.
I understand processing this form does not guarantee me a seat in any of the class(es) listed above. I also understand, as an ICP student, I am obligated
to adhere to the rules and regulations of the host university as well as my home university. I have read and understand the Louisiana Tech course load
policy.
ALL THE ABOVE STATEMENTS ARE TRUE AND ALL INFORMATION ON THIS FORM IS COMPLETE AND ACCURATE.
Student’s Signature Date
Advisor’s Signature Date
Department Head’s Signature Date
Academic Dean’s Signature Date
International Student Office Date
This student is authorized to enroll in a total of ______ hour(s) at the host university.
For Office Use Only
Student Graduating
Transcript Hold
Transcripts Received
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome