Quarter/Year

___________________

Student ID Number

________________________________

Name	_________________________________________________________________________________

(Last)

(First)

(Middle)

Address

______________________________________________________________________________

(Street)

(City)

(State)

(Zip)

Telephone

(_______)________________

E-Mail

__________________________________________

Class Level_________________

Major Field________________________

Date of Birth_____________

Course to be taken at UC, Riverside___________________________________________________________ INSTRUCTION TO STUDENTS Obtain necessary home campus approvals. Obtain host instructor's approval. Obtain host department chair's signature. Take application to host campus Registrar's Office. Return copy of approved application with all required signatures to the Records Office at CSUSB. If you change the course or withdraw, you must observe deadline at host institution. You are subject to its regulations and penalties for missing deadlines. Notify Registrar's Office at home campus of any changes in program.

NOTE:	Grade of "D" or "F" cannot be repeated and expunged. It is the student's responsibility to make sure the course will be transferrable.
APPROVALS

______________________________________________________________________________________

Home Campus:

Faculty Advisor or Department Chair

Date

______________________________________________________________________________________

Home Campus:

Dean's Office

Date

______________________________________________________________________________________

Home Campus:

Records Recorder (Certifying Eligibility and Fee Payment)

Date

______________________________________________________________________________________

Host Campus:

Instructor

Date

______________________________________________________________________________________

Host Campus:

Department Advisor / Chair

Date

______________________________________________________________________________________

Host Campus:

Dean's Office*

Date

______________________________________________________________________________________

Host Campus:

Registrar

Date

*	Either College of Engineering, College of Natural & Agricultural Sciences or College of Humanities and Social Sciences depending on department offering the course.