Summary: 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

Source: Anastasio, Thomas J. - Beckman Institute for Advanced Science and Technology & Department of Molecular and Integrative Physiology, University of Illinois at Urbana-Champaign

Collections: Biology and Medicine