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Please print clearly (Dyersburg State Community College)

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Agreement Intent to Enroll Form
Please print clearly
COMMUNITY COLLEGE STUDENT ID.
__ __ __ __ __ __ __ __ __
FULL LEGAL NAME P(Please Print)
LAST
FIRST
MIDDLE/MAIDEN
ADDRESS P(Please Print)
STREET ADDRESS
CITY
STATE
ZIP
COUNTY
(AREA CODE) PHONE NUMBER - HOME
(AREA CODE) PHONE NUMBER - WORK
PERMANENT HOME ADDRESS P(Please Print)
STREET ADDRESS
CITY
STATE
ZIP
COUNTY
E-MAIL ADDRESS P(Please Print)
We request your completion of the following for reporting purposes only. This information will not be used to discriminate against any applicant in the Partnership
Enrollment Program decision.
BIRTHDATE.
GENDER P
ETHNICITY / RACE P
(month / day / year)
(Check One)
Male
Female
Do you consider yourself to be Hispanic/Latino/Spanish origin? Yes No
Please select one or more of the following racial categories to describe yourself:
White Black or African American Asian American Indian Alaskan Native Native Hawaiian or Other Pacific Islander
_____ / ______ / ______
CITIZENSHIP P(Check One)
Are you a CITIZEN of the United States? Yes No (If no, what is your country of CITIZENSHIP and your VISA type?)
COUNTRY OF CITIZENSHIP
VISA TYPE
Are you seeking a degree from the University of Memphis? Yes No
If yes, indicate your planned major (If undecided, please state “undecided”):
What is your major at the partner Community College?
When is your expected graduation date
from the partner Community College?
When is your expected
entry term at the U of M?
Fall Spring Summer Year:
Release Notification: The partner Community College and University of Memphis will share and release information to each other about Partnership Enrollment
Program students. Please sign the student release form and return to the partner Community College Admissions Office. I certify that the information above is
true and complete to the best of my knowledge. I understand the eligibility for the Partnership Enrollment Program requires compliance with the provisions of the
Intent to Enroll agreement, including completion of the associate degree. I also understand that participation in this program may be denied if any of my
application information is found to be incomplete or inaccurate. I agree to comply with the deadlines for enrolling at the University. I understand and that I must
formally enroll in the University within one year of my associate degree completion.
STUDENT SIGNATURE.
DATE.
PARTNER COMMUNITY COLLEGE OFFICE USE ONLY.
PEP Official Signature
PEP Institution
Date
Total # AA/AS
Hrs Earned
Total # Hrs taken from
previously enrolled Institution
PEP Entry
Date
Classification
Expected Grad Date
APPROVED
DENIED
Initials
click to sign
signature
click to edit
Student Release Form
The student will participate in the Partnership Enrollment Program between the partner Community College and the University of Memphis beginning the semester
prior to earning no more than 30 hours of college-level university track coursework.
To be eligible for the Partnership Enrollment Program, the student must meet the following requirements:
1. Complete Partnership Enrollment Program Intent to Enroll Form prior to completing no more than 30 semester credit hours of college-level university
track coursework
2. Complete an Associate's degree university track (AA/AS)
3. Must be in academic and financial good standing at the partner Community College
As a Partnership Enrollment Program student, the student is entitled to receive the following services from the University of Memphis:
Guaranteed admission to the U of M while you are completing your associate degree, provided you comply with requirements.
Priority pre-registration in University courses for your first semester after graduation.
Access to academic advising and degree plans from both the partner Community College and U of M advisors throughout your tenure in the program.
Admission fee waiver
Access to U of M facilities and services such as the library and Art Museum.
Access to Student Affairs and Athletics prior to full admission
A Community College student who is ‘co-admitted’ to the U o M under the Partnership Enrollment Program may opt to purchase:
1. Access to a Parking Permit $30.00 per semester
2. Access to Campus Recreation & Intramural Services + Student Activities $65/semester AND/OR
3. Access to Student Athletic events via payment of FT Student Athletics Fee $225/semester
The following conditions apply:
1. The student's enrollment at the University of Memphis is governed by the terms and provisions of the Memphis Catalog in effect at the semester of
transfer or semester of acceptance of application.
2. Student must maintain enrollment for this agreement to remain in effect. If a student fails to enroll at the partner Community College and attain a
university track AA/AS degree, then the student will be required to submit a U of M Partnership Enrollment Admissions Form to the U of M Office of
Admissions and will be subject to the U of M university catalog at the time of application and enrollment.
3. Student will request an official copy of the high school record. If your high school graduation is through the General Education Development (GED)
program, have these scores forwarded to the office. You must submit scores earned on the ACT or SAT examination for consideration. Entrance
examination scores cannot be more than three years old at the time of enrollment.
4. Student will request an official copy of the academic record from each college or university in which you have enrolled.
5. Complete the Partnership Enrollment Program Admission Form
Deadlines for submitting the Partnership Enrollment Form:
Fall
Spring
Summer
Domestic Applicants:
July 1
December 1
May 1
International Applicants:
May 1
September 15
February 1
6. Do not attend another institution between the time you graduate and formally enroll at the University of Memphis.
7. Student will be eligible for acceptance to general degree programs once a university track AA/AS degree is granted, but certain degree programs will
require additional admissions requirements.
8. Student will comply with the U of M advising requirements.
9. The Student Affairs and Athletics fees would be tied to equivalent Program Services Fees paid by U of M students and would change accordingly; revenues
would accrue as if paid by U of M students.
10. The PEP student can purchase from the Parking Office what is referred to as a “Continuing Education” parking permit at $30 per semester to allow them
access to all general parking lots.
11. Student is subject to the academic and disciplinary policies of the enrolling institution. Additionally, student is subject to policies governing student use of
career counseling, and library when using those services.
12. Student understands that loss of eligibility to continue in classes at the partner Community College may cause termination of this agreement.
13. Student may cancel this agreement at any time upon written notice to the partner Community College office of Admissions.
By signing this agreement, the student authorizes the partner Community College and the University of Memphis to exchange all information on a regular basis
related to the student’s enrollment at either institution for purposes of maintaining academic, discipline and other appropriate student records as required to be
maintained by each institution, and asserts that he/she will meet Partnership Enrollment Program requirements as outlined above.
I understand that signatures below from the partner Community College and University of Memphis only acknowledge receipt of this agreement. This agreement is
not official until verification is made by the partner Community College and the University of Memphis that the student meets the Partnership Enrollment Program
requirements.
STUDENT SIGNATURE.
DATE.
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Completed 27 July 2020

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