Please Print Clearly


STUDENT NAME  ______________________        ADDRESS ________________________

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



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 Rutgers Biomedical and Health Sciences-RBHS (formerly 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 or School of Public Health.  Upon completion of the course the Registrar at Rutgers Biological and Health Sciences-RBHS (formerly 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 “RBHS 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.)  

NOTE: undergraduate students will register for the course 10:832:400 for the appropriate number of credits

 Course #                                                                                Title                                                                                         Permission Granted          
                                                                                                                                                                                               Insturctor's Signature











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 September 2013