Concurrent Enrollment Request Form – Fill Out and Use This PDF

Concurrent Enrollment Request Form

Concurrent enrollment is a status for students currently enrolled in courses at Belmont University and seeking to take additional courses at another institution. This form should not be submitted if a student is within thirty-two hours of completing a degree (if within 32 hours use a senior residency waiver form). Students must obtain approval from the Office of the Registrar each term prior to enrolling at a second institution. Students are held accountable for reviewing the concurrent enrollment policy which may be accessed in the current university catalog, http://www.belmont.edu/catalog under academic policies. Each section of this form must be completed and submitted to the Office of the Registrar (located in Freeman Hall, 1st floor next to Belmont Central) prior to registration.

Name: _________________________________________			Belmont ID: _______________________
(First)	(MI)	(Last)

Mailing Address: ____________________________________________________________________

(Street)	(City)	(State)	(Zip)
Phone Number: ____________________	Belmont e-mail address: ____________________________
(Area code & number)

Major: ___________________ Minor: ____________ Degree: _______________ (BA, BS, BM, BBA, BFA, BSN, BSW)

Class status: (circle) Freshman Sophomore Junior Senior

Anticipated term and year of graduation ____________ Academic Advisor __________________________

How many credit hours have you earned at another college or university? _________________________

Name, city and state of the institution(s): __________________________________________________________

Are you a current recipient of the Tennessee HOPE Scholarship? ________________

Please complete the following information as it pertains to the second institution. Attach a separate sheet and list each proposed course including the title, number and description printed directly from the institution’s catalog or website.

Re-typed descriptions will not be accepted. Please review the following link for a list of equivalent courses that meet general education requirements. http://www.belmont.edu/registrar/transcript_faqs/TBR_Transfer_Equivalency.html. Additional information regarding the transfer equivalency in the BELL Core may be located at http://www.belmont.edu/bellcore/pdf/transfer.pdf. *Please note that approval of this request does not guarantee course equivalency. Substitution forms should not be turned in with this sheet.

Name of second institution: ________________________________________________________________________

Address: ___________________________________________________________________________________________

(Street)	(City)	(State)	(Zip)
Term to attend institution (fall, spring or summer/year): _________		Circle: (semester or quarter) credit hours

How many total credit hours are you petitioning to take during the term? ______________.

List # credit hours registering at second institution ____; # Credit hours registering at Belmont, if applicable ___

Provide an explanation for the request to transfer credits from another institution.

____________________________________________________________________________________________________

____________________________________________________________________________________________

I have read the concurrent enrollment policy and the steps required to complete the process. I understand the provisions for this status and acknowledge it is my responsibility to inform my academic advisor and the Office of the Registrar of any necessary changes if permission is granted.

_____________________________________		_____________________________________
(Student Signature)	(Date)	(Registrar’s Office Signature)	(Date)

Please return to the Office of the Registrar located in Freeman Hall, 1st Floor	www.belmont.edu/registrar
Phone: 615-460-6619 Fax: 615-460-5415	10/2009