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Instructions: Please complete all items and then PRINT this form (it is not an electronic form submission process). A syllabus and course description must accompany all forms. This form must contain all signatures.

Campus Information:
Campus: Brandywine Semester of Delivery:
Course Abbreviation:
Number of Credits:
Course Number:
Course Title:  
Instructor Name:
Student is taking course for Honors credit: Yes | No
(If yes, Honors Independent Study Form must be included.)

Student Information:
Student Name:
Student Penn State ID :
Email Address: Phone:

Course Information:
Syllabus (including examination policy, basis of grade and academic integrity policy) must be attached; (required)
Course Description (approximately 200 words); attached (required)

Signatures Required :
Student: Date:
Instructor: Date:
Honors Adviser:
(Needed if student is taking as an Honors course)
Date:
Adviser: Date:
DAA: Date:

OFFICIAL USE ONLY

Instructor Compensation (to be completed by the DAA):
Not part of load, no extra compensation: (Entered as 2 in ARUAI)
Not part of load, extra compensation: (Entered as 3 in ARUAI)

(08/25/10)