The University of Texas Permian Basin & Midland College

Engineering Partnership

Student Information Request

First Name

Middle Name

Last Name

Email Address

I am interested in:

Transferring to UT Permian Basin

The Co-Enrollment Program

MC Student ID Number

Have you ever taken a class or been a student at UT Permian Basin?

Yes

No

UTPB Student ID Number

UTPB Hours

Classification

MC Hours

Cumulative GPA from Midland College

Mailing Address

Country

Street

City

Region

Postal Code

Cell Phone

How would you prefer we reach out to you?

Email

Phone call

Phone text

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Birthdate

Student's major or field of interest

Anticipated entry term at UT Permian Basin

Student Participation Agreement

I am pursuing a bachelor’s degree in CHEMICAL ENGINEERING from The University of Texas Permian Basin and will be enrolled in __(specify below)__ hours at Midland College for the term indicated above.

These hours will apply directly to my degree plan as documented by the UTPB degree plan.

I understand that this agreement covers only the term indicated above and I must complete a Student Participation Agreement for any future terms.

I agree to report any changes in my enrollment at either institution to the UTPB Financial Aid Office and Registrar’s Office within 5 days.

I understand that all financial aid disbursements that are in excess of amounts owed to UTPB (including, but not limited to tuition/fees, room and board, loans or other charges) will be released to the student as a refund via paper check or direct deposit. Student will be responsible for payment to Midland College once financial aid is dispersed.

Number of hours enrolling at Midland College

Your signature (your name will count as your signature)

Date of signature

I am pursuing a bachelor’s degree in ELECTRICAL ENGINEERING from The University of Texas Permian Basin and will be enrolled in __(specify below)__ hours at Midland College for the term indicated above.

These hours will apply directly to my degree plan as documented by the UTPB degree plan.

I understand that this agreement covers only the term indicated above and I must complete a Student Participation Agreement for any future terms.

I agree to report any changes in my enrollment at either institution to the UTPB Financial Aid Office and Registrar’s Office within 5 days.

I understand that all financial aid disbursements that are in excess of amounts owed to UTPB (including, but not limited to tuition/fees, room and board, loans or other charges) will be released to the student as a refund via paper check or direct deposit. Student will be responsible for payment to Midland College once financial aid is dispersed.

Number of hours enrolling at Midland College

Your signature (your name will count as your signature)

Date of signature

I am pursuing a bachelor’s degree in MECHANICAL ENGINEERING from The University of Texas Permian Basin and will be enrolled in __(specify below)__ hours at Midland College for the term indicated above.

These hours will apply directly to my degree plan as documented by the UTPB degree plan.

I understand that this agreement covers only the term indicated above and I must complete a Student Participation Agreement for any future terms.

I agree to report any changes in my enrollment at either institution to the UTPB Financial Aid Office and Registrar’s Office within 5 days.

I understand that all financial aid disbursements that are in excess of amounts owed to UTPB (including, but not limited to tuition/fees, room and board, loans or other charges) will be released to the student as a refund via paper check or direct deposit. Student will be responsible for payment to Midland College once financial aid is dispersed.

Number of hours enrolling at Midland College

Your signature (your name will count as your signature)

Date of signature

I am pursuing a bachelor’s degree in PETROLEUM ENGINEERING from The University of Texas Permian Basin and will be enrolled in __(specify below)__ hours at Midland College for the term indicated above.

These hours will apply directly to my degree plan as documented by the UTPB degree plan.

I understand that this agreement covers only the term indicated above and I must complete a Student Participation Agreement for any future terms.

I agree to report any changes in my enrollment at either institution to the UTPB Financial Aid Office and Registrar’s Office within 5 days.

I understand that all financial aid disbursements that are in excess of amounts owed to UTPB (including, but not limited to tuition/fees, room and board, loans or other charges) will be released to the student as a refund via paper check or direct deposit. Student will be responsible for payment to Midland College once financial aid is dispersed.

Number of hours enrolling at Midland College

Your signature (your name will count as your signature)

Date of signature

Student Financial Aid Agreement/Release Form

I:

Give the University of Texas Permian Basin and Midland College permission to share my academic and financial aid records of information. I understand that such records will be used in compliance with the FERPA Right-to-Privacy Act to determine my eligibility for this program and financial aid.
I further agree to allow Midland College to apply all future certificates or degrees that I may qualify for to my academic record.
I understand that during periods of enrollment where I am enrolled at both institutions, and taking 6 credit hours or more per semester at UTPB, I will only receive funding from the University of Texas Permian Basin (the home institution). Financial Aid will be awarded based on number of hours attending at both UTPB and MC. Funds will be used to pay UTPB first and any unspent funds will be issued to student to pay MC.
I understand that during periods of enrollment where I am only enrolled at one (1) of the institutions, I will receive funding from that institution.
I understand that my eligibility for federal and state financial aid may be determined at both institutions upon student request.
I understand that I will only receive federal or state funding for hours that I am enrolled in from both institutions as long as I stay enrolled in the Consortium.
I agree to abide by the policies and procedures of the college which is providing state or federal funding.
I understand that I must file a signed copy of this agreement for each semester that I am enrolled in the Consortium.

Financial Aid Office
Midland College
3600 N. Garfield St.
Midland, TX 79705
FICE code 009797

Financial Aid Office
University of Texas Permian Basin
4901 E. University Blvd.
Odessa, TX 79762
FICE code 009930

Your signature (your name will count as your signature)

Date of signature

Information collected about you through this application may be held by any institution of higher education to which you apply. With few exceptions, you are entitled upon request to be informed about the collected information. Under sections 552.01 and 552.023 of the Texas Government Code, you are entitled to receive and review the information. Under Section 559.004 of the Texas Government Code, you are entitled to correct information held by an institution that is incorrect. You may correct information held by any institution to which you apply by contacting the institution’s Registrar. The information that is collected about you will be retained and maintained as required by Texas records retention laws (Section 441.180 et. seq. of the Texas Government Code) and rules.