This form permits a Kentucky State University student to attend another institution as a visiting student. By completing this form, all parties agree to accept the course in transfer. To successfully transfer the course to Kentucky State University, the student must pass the course with a grade of "C" or better. An official transcript of the course must be sent from the visiting institution to Kentucky State University, Transfer Center Coordinator, ASB Suite 323, East Main Street, Frankfort, KY 40601. This form must be completed and the course approved prior to the student enrolling at the other institution. This form is null and void if students' academic standing changes at the end of term. Only courses listed below will be accepted.

Student Name: ___ Social Security Number: ___

Session/Term to attend other Institution:_____ Year:_____ Major:_____

Visiting Institution: ___

Address of Institution (required) ___

COURSE(S) TO BE TAKEN

COURSE NUMBER COURSE TITLE CREDIT HOURS UNDERGRAD/ GRADUATE KSU EQUIV. COURSE

Student Signature: ___ Date: ___

Advisor Signature:___ Date:___

Date:

Date:

Chairperson/Dean Signature: ___

Date:___

(*Undeclared - Director of Academic Advising)

Registrar's Office: _____ Date: _____

(Required for Official Approval)

Date:

This document is not official without the University Raised Seal.

Good Standing: □ Yes □ No

Seal

Effective Date:___

Classification:___

GPA: ___ Current Enrollment Status: ☐ Full Time

□ Part Time

Date Sent:___