Florida State College at Jacksonville

Program Objective Change Request Form

For FSCJ Dual Enrolled Students

Student's Name

Student's DOB

FSCJ Student I.D. (SID)

Dual Enrollment students are encouraged to speak with their Dual Enrollment Coordinator as some programs are identified as
limited access. Note: Once your program objective is declared, changing your primary program objective could negatively
impact your financial aid eligibility. Students receiving veterans benefits must also complete VA form 22-1995 or 22-5495
and submit it to the FSCJ veterans affairs office for process handling.
Current primary program objective:
Program Title: DUAL ENROLLMENT

Program Objective Number: 3408

Indicate the program objective that you want to pursue after high school:
Please be specific refer to the College Areas of Study Web page at fscj.edu/academics/areas-of-study or call us at
904-646-2300 to speak with a representative if unsure of the specific program title and number.
Program Title:

Program Objective Number: ______

Note that this program will become your new primary objective.
Circle the term/year below to indicate when your new primary program objective is to become effective:
Summer 2015

Fall 2015

If selecting the Associate in Arts program:

Indicate your intended Transfer Major: _____________ Transfer Institution:________________________________________________
Students changing to the Associate in Arts (A.A.) must also indicate an intended Transfer Major and Institution. To indicate
your intended A.A. Transfer Major, please refer to the list provided. Input the appropriate Transfer Major code and Transfer
Institution in the fields provided above.
Dual Enrollment students: If changing to a degree seeking program objective, upon graduation you must provide an official
High School or equivalent transcript indicating the date of your graduation. If graduating from a public high school in Duval,
St. Johns or Clay county, the College will request an official transcript on or after July 1, 2015. List the name of your high
school on the space provided below.

Name of High School

City

State

Graduation Date

Parents Signature:

Date:

Student's Signature:

Date:

All signatures are required. Submit this form for processing and handling. We have several ways in which to return
the form:

Scan/Email document to: posrequest@fscj.edu

Fax to: (904) 633-5955; (888) 873-1145
Hand deliver to your nearest campus Welcome Center location
Hours: Mon.-Thurs., 8 a.m.6 p.m.; Fri., 8 a.m.3 p.m.; Sat. and Sun., Closed