Course Shell Request Form

First Name: *

Last Name: *

UHart Email: *

Department: *

Department Program Director Name: *

Builder Name (SME): *

Type of Course Needed: *

Additional Information (check all that apply):

Specify third party publisher materials if applicable:

If course type is other, please clarify course details:

Course Code and Number: *

Course Name:

Course Copied From (if applicable):

Course Copied To (if applicable):

Required Completion Date: *

Stipend Amount (if applicable):

Other Comments/Notes: