APPENDIX E

Course #______ Section #______ Student Name ______________________________________________________________

Student Records Office

Montana State University-Northern

BOTH SIDES OF THIS FORM MUST BE COMPLETED BEFORE APPROVALS WILL BE GRANTED

Approval of this form permits the student to pursue independent work under the supervision of a faculty member. The faculty member will assign a three-digit number to the course. The first number will indicate the level of the work to be performed. The number will end in 99, which indicates that the course was taken by independent study. All courses will have the prefix of the discipline under which the course is taught. For example, AUTO299 indicates that the course is an independent study, taught within Automotive Technology, and is at the Sophomore level. If a course which is listed within the regular curriculum is taught by independent study, the prefix, title and level designation number of the course will be the same, but the last two numbers will be 99. For example, BUS 100, Introduction to Business, would become BUS 199, Introduction to Business when offered as an independent study.

If this is a regular College course, write its course number and title here

If this is not a regular College course, write the course description here:

Why is it necessary to offer this course by independent study?

Objectives (concepts and skills which the student will be expected to understand or perform):

Texts and other instructional materials:

Equipment (as appropriate):

See reverse for authorizations

Authorizations to Offer an Independent Study Course

Course prefix ____________Course number _______Course Title___________________________________________

I, _________________________________________________, understand that when the Student

Print Name

Records Office receives this form with all authorizations complete, I will be registered for the course defined by this form.

Student Signature __________________________________________________________ Date _________________________

Student ID Number _____________________________________

Each of the following must endorse this request. When the form is completely endorsed, forward it to the Student Records Office.

Instructor Signature ________________________________________________________________________ Date_________________

Department Chairperson Signature _____________________________________________________________Date _________________

Vice President for Academic Affairs Signature ____________________________________________________ Date _________________

Department office use only:

Course entered into schedule by:

Name _______________________________________Date ____________________

Student Records Office use only:

Student registered by:

Name _______________________________________Date _____________________