Section 1

Please provide the following information. If you do not feel comfortable providing your Social Security Number via this form, please email our office.

Is this request for:

Spring

Summer I

Summer II

Fall

Name:

Blinn ID:

Address:

City, State, Zip:

Valid Phone Number:

Valid Email Address:

Previous Distance Learning Experience: **Select one** None 1-3 Internet Courses 1-3 Blended Courses More than 4 DE Courses

Section 2

Note: If you are not a current Blinn student, you will need to become one before I can process your request.

Are you a current Blinn Student, meaning you have attended Blinn College during the current or previous semester?

Yes

No

In Progress

Are you graduating this semester?

Yes

No

If yes, where are you graduating from?

Section 3

Course Requested (Example: PHIL 2306, not the title of the course):

Have you looked at the VCT web site for availability?

Yes

No

If yes, please list your preferred college: With regard to your preferred college, we will do our best to accommodate your request. However, in some cases, another college will be picked due to fees or previous experience.