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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:
Approval signatures below as applicable:
Faculty Signature Print Name
Division Chair Signature Print Name
Vice Chancellor Academic Affairs Print Name
Registrar certification:
Credit has been recorded to the student’s transcript.
Registrar Print Name
Registrar to file this form and original PLA application.
Date
Date
Date
Date
Rev. June 16, 2015 Page 1 of 1
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