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TRANSFER STUDENT REFERENCE SHEET OFFICE OF ADMISSIONS BOX 9901 SOUTHERN UNIVERSITY BATON ROUGE LOUISIANA 70813 Provide the requested information below and send to the Chief Student Affairs Officer of the college/university you last attended. This form should be done at the time you request your official transcripts. Your application is considered incomplete until this form is returned* TYPE OR PRINT ALL INFORMATION* PART I TO BE COMPLETED BY THE TRANSFERING STUDENT NAME OF STUDENT HOME ADDRESS SEMESTER YOU EXPECT TO TRANSFER SOCIAL SECURITY NUMBER DATE OF BIRTH I authorize you to release the requested information below by completing this section of the form and return to Southern University Office Admissions. APPLICANT S SIGNATURE Check the type of institution student attended Why did this student leave your institution Has the student been under Disciplinary Censure If yes please describe College/University Yes Is the student eligible to return to this institution If no please explain ineligibility If yes please explain conditional eligibility Community College Technical School No Additional information that may be of value to us in working with this student. SIGNATURE TITLE DATE INSTITUTION S NAME ADDRESS ZIP CODE Southern University and A M College Baton Rouge Louisiana 70813 225 771-4500. Your application is considered incomplete until this form is returned* TYPE OR PRINT ALL INFORMATION* PART I TO BE COMPLETED BY THE TRANSFERING STUDENT NAME OF STUDENT HOME ADDRESS SEMESTER YOU EXPECT TO TRANSFER SOCIAL SECURITY NUMBER DATE OF BIRTH I authorize you to release the requested information below by completing this section of the form and return to Southern University Office Admissions. APPLICANT S SIGNATURE Check the type of institution student attended Why did this student leave your institution Has the student been under Disciplinary Censure If yes please describe College/University Yes Is the student eligible to return to this institution If no please explain ineligibility If yes please explain conditional eligibility Community College Technical School No Additional information that may be of value to us in working with this student. APPLICANT S SIGNATURE Check the type of institution student attended Why did this student leave your institution Has the student been under Disciplinary Censure If yes please describe College/University Yes Is the student eligible to return to this institution If no please explain ineligibility If yes please explain conditional eligibility Community College Technical School No Additional information that may be of value to us in working with this student. SIGNATURE TITLE DATE INSTITUTION S NAME ADDRESS ZIP CODE Southern University and A M College Baton Rouge Louisiana 70813 225 771-4500. Your application is considered incomplete until this form is returned* TYPE OR PRINT ALL INFORMATION* PART I TO BE COMPLETED BY THE TRANSFERING STUDENT NAME OF STUDENT HOME ADDRESS SEMESTER YOU EXPECT TO TRANSFER SOCIAL SECURITY NUMBER DATE OF BIRTH I authorize you to release the requested information below by completing this section of the form and return to Southern University Office Admissions. APPLICANT S SIGNATURE Check the type of institution student attended Why did this student leave your institution Has the student been under Disciplinary Censure If yes please describe College/University Yes Is the student eligible to return to this institution If no please explain ineligibility If yes please explain conditional eligibility Community College Technical School No Additional information that may be of value to us in working with this student. SIGNATURE TITLE DATE INSTITUTION S NAME ADDRESS ZIP CODE Southern University and A M College Baton Rouge Louisiana 70813 225 771-4500. .

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