THE CALIFORNIA STATE UNIVERSITY
APPLICATION FOR INTRASYSTEM CONCURRENT ENROLLMENT
(See instructions on accompanying sheet)		 C

This application is to be used by California State University students who wish to enroll concurrently at another CSU campus.

PART I. TO BE COMPLETE BY STUDENT
A. 1.  Home Campus ______________________________  2. Proposed host campus________________________________

3.  Semester/Quarter of enrollment: Home__________ Host__________ 4.   Home campus file no.___________________

5.  Previously attended the proposed host campus?  ____ No    ____Yes   If yes, last term of attendance?______________

6. Legal Name______________________________________________________________________________________
(Last) (First) (Middle) (Maiden)
7.  Student ID Number __________________________ 8.  Date of birth _________/ _________/ _________
  (Month) (Day) (Year)
9.  Mailing Address ___________________________________________________________________________________
(Street) (City) (State) (Zip Code)
10. Home Phone ______________ Message Phone________________ 10b. E-Mail____________________________

11.  Class level at time of planned enrollment: ___Freshman ___Sophomore ___Junior ___Senior ___Graduate

12.  Major field__________________________________ and/or credential objective___________________________

13.  Indicate any major physical handicap for which some assistance or consideration should be provided.

  ___________________________________________________________________________________
14.  Have you ever applied for or been awarded financial aid?    ___Yes    ___No 14a. Sex     ___Male    ___Female

B. Listing of course(s) planned at host campus: (If a planned course is a major requirement at the home campus, approval of the department chair at the home campus is required).
Courses at host Campus Units
Q    S		 Equivalent Courses at Home Campus Units
Q    S		 Department Chair Approval
             
             
             
             
No. of units planned at home campus ___________

I certify that the information I have entered above is true and that I have read and understand the eligibility requirements, enrollment conditions and procedures as stated.
Signature____________________________________________ Date________________

PART II. TO BE COMPLETED BY HOME CAMPUS

Residence status for fee purpose   ___ Resident     ___ Nonresident
County of residence________________________________with code of______________________
International (Visa) student at time of enrollment   ___ Yes      ___ No
                              Maximum total units approved___________

REGISTRAR"S CERTIFICATION: I certify that this student's residence and academic status are correct according to the official records of this campus, that the student qualifies for concurrent enrollment, and that such concurrent enrollment is approved.

Signature___________________________________________Date________________________
Title________________________________________Home Campus_______________________

PART III. TO BE COMPLETED BY HOST CAMPUS
A. Approval for enrollment at host campus:    ___Granted    ___ Denied Date ______________
Remarks___________________________________________________________________
Signature_________________________________ Home Campus_______________________
B. The student registered: Date_______________________ No. of Units___________________
Signature______________________________________ Title__________________________
Host Campus_________________________________________________________________






FEE PAYMENT
CERTIFICATION








CAMPUS SEAL OR STAMP







NONRESIDENT
TUITION CERTIFICATION