PROGRAM TRANSFER REQUEST

Part I: (Student please fill out part I)

Name ______Student ID No.______

Address ______

No. & StreetCityState Zip Code

Telephone No. ______

I request change from:Current Program ______

I request change to:New Program ______Day □Evening □

Entering Semester:Fall ______Spring______

Reason for Request (continue on back if necessary) ______

Student ______Date ______

Signature

Student must meet with and submit this form to their Academic Advisor.

Part II: ACADEMIC ADVISOR (please fill out reverse side)

□ I certify that this student has successfully fulfilled or is in the process of completing the admission requirements.

□ This student has not fulfilled the admission requirements.

Advisor ______Date ______

Signature

Student must submit this form to the Program Director after meeting with their Academic Advisor.

Part III: PROGRAM DIRECTOR

DECISION
This student has been Accepted □ Denied □ to this program
* Acceptance does not guarantee placement into program. / FOR HEALTH SCIENCE RELATED PROGRAM CANDIATES:
□ Student will be ranked and notified of a decision upon completion of all admission requirements and space availability. Student may register for general studies courses until a final decision has been rendered.

Conditions of Acceptance / Comments: ______

______

Program Director ______Date ______

Signature

Program Director must submit this form to the Registrar.

This form serves as an official notification of acceptance or denial into program.

OFFICE USE ONLY: Date Received by Registrar ______Copy to: Student, Admissions, Advisement, Program Director

(over)

Program Transfer - Advisement Analysis

Admission requirements are found in the Catalog under admissions and under each program.

Program Transferring To: ______

High School Background:Cumulative Average: ______

Course Name / Exam Grade / Final Grade
One year of high school algebra or integrated math
A second year of high school mathematics
beyond one year of algebra
Biology
Chemistry
Physics

General Education Diploma (GED) Score: ______

ACCUPLACERScores: / Reading: / Score / Cut off 70 / Placement in EN095
Sentence Skills: / Score / Cut off 82 / Placement in EN099
Elementary Algebra:: / Score / Cut off 25 / Placement in MA096
Score / 26-57 / Placement in MA097, or Eligible to take MA107/PH107
Score / 58--76 / Eligible to take MA111
Score / 77 or above * / Eligible to take MA 111 or MA112
Computer Literacy: / Score / Cut off 40 / Placement in BU099

*Student has option of taking MA 107/PH107, MA 11, or MA 112

College Background:(if transfer student, please list for each college attended)

Name of College / Final Semester Average / Cumulative Average
1.
2.
3.
4.
5.

GS100 (College Seminar) ______ (if taken)

Grade

Transitional Studies Courses(if taken) / Science Courses(if taken)
Grades / Grades / Grades / Grades
EN095: / GS101: / BIO105: / BIO130:
EN099: / GS102: / CH100: / BIO130L:
MA096: / BU099: / PHY099: / BIO131:
MA097: / BIO131L:
EN095-Intermediate Reading / GS100-College Seminar / BIO105-Human Biology / BIO130/130L-Anatomy &
EN099-Basics of Composition / GS101-Info. & Research Basics / CH100-Intro. to Chemistry / Physiology I/Lab
MA096-Pre-Algebra / GS102-College Success / PHY099-Preparatory Physics / BIO131/131L-Anatomy &
MA097-Intro. to Algebra / BU099-Computer Literacy / Physiology II/Lab
Comments:

(Revised 4/12)