Cooperative Agreement Application

Step 1 of 2: Submit

To apply for a cooperative agreement, please fill out this form, including transcripts and program acceptance letter, if required.

Complete this form if you wish to attend another Illinois community college for a program that Prairie State College does not offer.
Please allow up to two (2) weeks for processing your application.

1. Email address: 2. First Name: 3. Last Name: 4. Address (number & street): 5. City:

6. State: Illinois Indiana Other:

7. Zip Code: 8. Phone Number: 9. Date of Birth:

10 Please upload a PDF verifying your residency at the address you listed above. The document must show your first & last name and address. We cannot accept documents showing only the name of another resident at your address. Acceptable documents include the following:

Valid driver's license or state ID
Utility bill
Property tax record
Lease agreement
Insurance card
Voter registration card
Posted mail addressed to you

Please remove any identifiable information (e.g. account numbers) other than your name & address.

File Attachment:

11. Is this a renewal of an existing cooperative agreement? Yes (Skip to question 12) No (Skip to question 13)

Renewal of Existing Cooperative Agreement

12 Please upload your most recent grade report or unofficial transcript showing your current GPA.

File Attachment:

Status at PSC

13. What is your status at PSC? Current Student at PSC Former Student at PSC Never Attended PSC

14. PSC ID Number:

Program at the Receiving College

Cooperative agreements can only be issued for current or future terms. Past terms are not eligible. Approved agreements are valid for up to one year from the start term (they may be renewed annually if you remain eligible).

15. For what term are you requesting the cooperative agreement to begin? Fall Spring Summer

Other year: 17. What is the name of the college you want to attend?* Other college:

18. What type of credential does the program provide? Certificate (non-degree) AAS - Associate in Applied Science AS - Associate of Science AA - Associate of Arts BA or BS - Bachelor of Arts/Science Other (complete next field):

Other credential: 19. What is the name of the specific program you want to pursue? 20. Please provide a link to the specific program you wish to pursue at the other college.

Selective Admission Programs

Selective admission programs have prerequisites beyond a high school diploma or GED. Many Allied Health programs such as Nursing, Dental Hygiene, or Physical Therapist Assistant are selective admission programs. If you have an acceptance letter to the program (not the college), the program is a selective admission program.

21. Is the program a selective admission program? Yes (Skip to question 22) No (Skip to question 23)

Students applying for a cooperative agreement for a selective admission program must show evidence that they have been accepted to the selective admission program before the cooperative agreement can be approved.

22. Upload your acceptance letter to the selective admission program

Additional Documentation

23. Upload any additional documentation to support your application.

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I Agree.

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I Agree.

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I Agree. 27. Sign your name below to indicate agreement with the above.

Date: Saturday, 23 November 2024 (EST)

Name:

Type your name to sign this document:

Typing name is equivalent to a handwritten signature

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