Application for Concurrent Registration
Last Name: First Name:
UIN:
Street Address
City State Zip Code
Daytime Telephone
Date
Applicant's Signature
Middle Initial:
Date of Birth:
MO DAY YR
E-mail
Applicant's Mailing Address:
I am presently enrolled in the College of
at:
Chicago Springfield Urbana
List courses in which you wish to enroll at the Secondary Campus:
I understand that if participation in the Concurrent Registration Program causes a change in my tuition and fees, I will be responsible for all charges
assessed.
OFFICIAL USE ONLY
Please complete, sign, and obtain an appropriate signature of authorization from your home college. The home college should review the
proposed courses and approve their transfer. The completed form should then be submitted to the Registrar's Office on the home campus by
the appropriate deadline. Deadlines are May 15 for summer, August 15 for fall, and December 15 for spring.
PRIMARY CAMPUS
at:
Chicago Springfield Urbana
SECONDARY CAMPUS
I am applying for Concurrent Registration
Primary Campus Program Code
Secondary Campus Program Code
College Approval (Primary Campus)
College Approval (Secondary Campus)
Residency
Citizenship
UNIVERSITY OF ILLINOIS
Summer
Term Year
M
F
Sex:
County
10-25-10
Subject/Course Number CRN Hours HoursCRNSubject/Course Number
HoursCRNSubject/Course Number HoursCRNSubject/Course Number
Demographic Information:
Fall
Spring
