Bluegrass Community & Technical College
REQUEST FOR SPECIAL EXAMINATION FOR CREDIT
Student Instructions:
1. Fill out Part 1 of this form.
2. Turn in form with Part 1 completed to the Division Assistant Dean.
3. If the Assistant Dean approves your request, he/she will coordinate with instructor to facilitate administration
of the examination.
___________________________________ _____________ ________________________
Name (please print) Student ID Major
Part I: To be completed by student.
I request permission to take a special examination for credit in
________________________________________ ____________________________________
Course Title and Number Instructor of Course
__________________________________________ ___________________________________
Student’s Signature Date
Part 2: To be completed by the Assistant Dean of the Division administering the examination.
The above request is is not approved
__________________________________________ ___________________________________
Assistant Dean’s Signature Date
Part 3: To be completed by the Instructor. Return to the Assistant Dean when completed.
Results of the examination: Pass Fail (Select one.)
__________________________________________ ___________________________________
Instructor’s Signature Date
Part 4: To be completed by the BCTC Registrar.
__________ credit recorded on permanent transcript in accordance with the Rules of the Senate of the
Kentucky Community an Technical College System, Section V,1.1.4. Current semester record of
enrollment adjusted, if appropriate.
__________________________________________ ___________________________________
Registrar’s Signature Date
After completion of Part 3, all copies should be forwarded to the BCTC Registrar.
After completion of Part 4, copies are distributed as follows: Original to student, copies to Registrar and Division Assistant Dean.
