______________________________________________
Policy Guideline No. 4-16 Attachment 2
Rev. April 25, 2016
KAUA’I COMMUNITY COLLEGE
Request for PLA Credit for Non-Collegiate Sponsored Education (NCSE)
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:_______________
Name of the NCSE Program or Course:
Sponsoring Organization Offering the Training: _______________________________________
Number of Hours: ___________________ Date NCSE Training Completed: _______________
Certificate Awarded? (Yes/ No) Instructor Name: _________________________________
Proof of Completion Attached? (Yes/No)
What Kauai CC course(s) would you like credit for based on this NCSE?
Course Alpha & Number
Name of Course
Number of Credits
Authorizations:
Academic Advisor: I have discussed NCSE with student and verify that the training described
IS IS NOT listed in the KCC NCSE list of approved training:
_____________________________
Academic Advisor Signature
__________________________
Print Name
__________
Date
Division Chair: Please check the option 1 or 2 below:
_____1. KCC NCSE list of approved training: I have reviewed this application and
approve the awarding of NCSE credit as listed in the attached PLA Credit Award
Form. A processing fee will be assessed from the student.
_____2. Training not on the KCC NCSE list of approved training: I have discussed this
request with the student and
agree disagree to authorize the PLA
evaluation requested above.
If “agree,” specify name of faculty reviewer: ___________________________________
