Application for Cross Enrollment to the University of California, Berkeley- LIVE

Application for Cross Enrollment to the University of California, Berkeley

Home Institution: Santa Rosa Junior College Host Institution: UC Berkeley

Student Name*

First Name

Last Name

SRJC Student ID Number (SID) *

Date of Birth*

Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Email*

Phone*

Semester of Cross Enrollment*

Fall Spring

Year of Cross Enrollment*

Did you previously attend UC Berkeley?*

Yes No

What was the last semester attended? *

UC Berkeley Course Department and Number*

UC Berkeley Course Title*

Does the course have a prerequisite?*

Yes No

How was the perquisite for the course met?*

Reason for taking course*

Course not available at home institution Complete transfer requirement

Other:

I certify the information provided is accurate, and that I have read and understand the eligibility requirements, enrollment conditions, and procedures as stated.*

[clear]

Use your mouse or finger to draw your signature above

Name and phone number of SRJC Transfer Director*

Signature of SRJC Transfer Center Director

HOST CAMPUS CERTIFICATION (Berkeley)

Dept

Course #

Section #

Course Code:

Units:

Instructor Approval (signature) and date

Fee Received

Cross enrollment Status (Approved/Denied)

Staff Signature and Date