KCCP 4-16 Attachment 4

KAUA’I COMMUNITY COLLEGE PLA CREDIT AWARD FORM Please attach the signed PLA Request Form, with receipts attached, and personally deliver or send to the Registrar. Students cannot send or deliver this form.

Student’s Name: _________________________________ UH ID#______________ Last

First

MI

Type of PLA Credit to be Awarded (check one): Credit-by-Institutional Exam: _____ Non-Collegiate Sponsored Education: _____ Portfolio Assessment: _____ Equivalency Exam (specify type; e.g., CLEP): ____________________________________ Course Information: Complete the table for the courses for which credit is being granted: Course Alpha & Number

Name of Course

Number of credits

Approval signatures below as applicable: _____________________________

__________________________

__________

Faculty Signature

Print Name

Date

_____________________________

__________________________

__________

Division Chair Signature

Print Name

Date

_____________________________

__________________________

__________

Vice Chancellor Academic Affairs

Print Name

Date

Registrar certification: Credit has been recorded to the student’s transcript. _____________________________

__________________________

__________

Registrar

Print Name

Date

Registrar to file this form and original PLA application.

Rev. June 16, 2015

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