Fillable Credit By Examination Petition Form (California State University, Dominguez Hills)

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Credit By Examination Petition Form (California State University, Dominguez Hills)

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The Credit By Examination Petition Form (California State University, Dominguez Hills) form is 1 page long and contains:

  • 6 signatures
  • 16 check-boxes
  • 25 other fields

Country of origin: US
File type: PDF

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Credit By Examination Petition Form
Office of Admissions and Records (WH 290)
FOR ADMISSIONS AND RECORDS OFFICE USE ONLY
Test Administered
Yes □
No □
Examination Date:
Grade to be Awarded:
Faculty Signature:
Date:
DATE RECEIVED IN A&R
Date Stamp and Initial
Cashier’s Stamp Document
Processing fees received:
Instructions:
1. Meet with an advisor to discuss Credit By Examination eligibility and regulation requirements.
2. Complete a separate Credit by Examination petition form for each request.
3. Complete, with an advisor, the Eligibility Determination section.
4. Obtain the appropriate signatures and pay applicable fees.
Course Identification (Example: SPA 100, Elementary Spanish I, 5.0): TERM (Circle One) Fall Spring Year: _____
Dept Course # Course Title Units
Eligibility Determination (Complete with an Advisor):
1. Is the student currently enrolled at CSU, Dominguez Hills? Yes ___ No ___ How Many Units? _____
2. Does the student have an overall GPA of 2.0 or higher? Yes ___ No ___
3. Has the student completed a minimum of 12 units at CSU,
Dominguez Hills? Yes ___ No ___
4. Has the student earned any units by Credit-by Examination? Yes ___ No ___ How Many Units? _____
Student: I understand that by signing this form, I will be obligated to pay all associated fees.
Student Signature and Date Advisor’s Signature and Date
Instructor of Record Identification and Division Authorization:
1. Faculty member is willing to develop, administer, and grade examination. Yes ___ No ___
2. Faculty member agrees to submit grade according to current semester deadlines.
___________________________________________ ____________________________________________
Faculty Name (Please Print) Faculty Signature and Date
3. Approved ___ Denied ___ ____________________________________________
Department Chair Signature and Date
4. Approved ___ Denied ___ ____________________________________________
Dean Signature and Date
STUDENT ID:
LAST NAME:
ADDRESS:
CITY:
STATE:
ZIP CODE:
EMAIL:
Last Updated: March 23, 2020
Please email the completed form with required signatures to admit@csudh.edu
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Credit By Examination Petition Form (California State University, Dominguez Hills)

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Completed 18 August 2020

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