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Policy Guideline No. 4-16
Rev. April 25, 2016
Attachment 1
KAUAI COMMUNITY COLLEGE
Request for PLA Credit by Exam
Credit by Institutional Exam (CBIE) or National Standardized Equivalency Exam (NSEE)
Students must pay the requisite fees and attach receipts to this form for request to be complete.
Name:
_
_________________
__
_________________
__
___
UH Number
_________________
Last First MI
Phone: ____________________ UH Email: _
_____________________
Major:
_
Type of PLA requested (check one):
_______________
Credit by Institutional Exam (CBIE)
National Standardized Equivalency Exam (NSEE)
Fill in below what course you are requesting PLA credit:
Course Alpha & Number
Name of Course
Number of Credits
Academic Advisor:
I have provided the PLA policy guidelines KCCP 4-16 to the student.
The CBIE or NSEE is recommended for the requested course.
I have discussed PLA benefits and risks with this student:
Academic Advisor Signature Print Name Date
Faculty: I have discussed this request with the student and
_
___a
gree (fee assessed)
___
disagree (no fee assessed) to authorize this PLA evaluation:
If declined, please explain here and initial:
PLA Fee * (CBIE – 50% regular tuition; NSEENo Fee)
*PLA f ee is non-refundable even if n o credits a re awarded
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Faculty Signature Print Name Date
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Student Signature Print Name Date