Please Print Clearly

STUDENT NAME  ______________________        ADDRESS ________________________

STUDENT ID #  _________ _____ _________  _______________________                                                                                                               SCHOOL  _____________________ ________ TELEPHONE______________________
SSN  __________________________ GENDER ____       D.O.B. ______________________

RUTGERS UNIVERSITY/UMDNJ-RWJMS, GSBS, SPH CROSS REGISTRATION

TO__________________________________                                   DATE_________________

The Instructor-RWJ Medical School or Graduate School of Biomedical Science or School of          Public Health
______________________________, is a graduate student enrolled at Rutgers University. 
It is requested that he/she be permitted to attend the course(s) indicated below during the
______________________term, and that upon completion of the term, his/her grade be submitted to the UMDNJ Registrar via regular grade submission (student will be on your roster).       

SIGNATURES____________________________        ________________________________                                                                                                  Student’s Adviser                                           Student’s Dean

_____________________________________________________________________________

This form should be completed by the student and routed as follows:

1.         Obtain your adviser’s and dean’s signature (secure a special permission number from the dean, if necessary—see #4 below);

2.         Obtain the signature of the course instructor for consent to enroll;

3.         Submit form to the Registrar, Robert Wood Johnson Medical School or Graduate School of Biomedical Science.  Upon completion of the course the Registrar at UMDNJ will send a transcript of your grade(s) to the Graduate Registrar at Rutgers University for inclusion on your Rutgers transcript.

4.         You must register for “UMDNJ Exchange” (16:001:815 or 34:001:815, depending on your school of registration) using the index number listed in the Rutgers New Brunswick graduate class schedule for the same term for the appropriate number of credits.  A special permission number obtained from the Dean is required for 16:001:815, but not for 34:001:815.  (This pseudo-course is not graded--for billing purposes only.)  

TO:    REGISTRAR-Robert Wood Johnson Medical School, or
          REGISTRAR-Graduate School of Biomedical Science, or
          Medical_School.htmlREGISTRAR-School of Public Health                                                     

             Please send my grade(s) via official transcript to the Graduate Registrar, Rutgers University, Piscataway, NJ

STUDENT SIGNATURE  _________________________________________________________ 

Richard Bird,  Registrar
Rutgers University  Oct. 2007