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First Name
M.I.
Last Name Delta Student ID Number
Daytime Phone Number E-mail Address
DIVISION CHAIR APPROVAL ___________________________________________ DATE:
Amount received: Received
by:
Date:
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Louisiana Delta Community College
Request for Credit for Prior Learning
Challenge Credit for Prerequisite Not Taken Portfolio Assessment
Step 1: Student Information (to be completed by student)
I request approval to receive prior learning credit for the following course(s):
Students must be currently enrolled at Louisiana Delta Community College to apply for Prior Learning credits.
Step 2: Type of Credit and Courses Requested (to be completed by student and submitted to appropriate division chair for approval)
The type of prior learning credit I am requesting is: (please check one)
Challenge Portfolio Assessment MOU Agreement
I am requesting credit for the following semester/year:
Semester (please check one) Fall Spring Summer
Subject/Catalog # Title Credits Faculty (Print Name) Date
Registrar
Step 3a: Fee Payment (to be completed by department)
Type of Credit (please check one)
Challenge – department prepared test
Challenge – externally prepared test
Portfolio Assessment/MOU Agreement
Type of Credit
(please check one)
Fee Per Course Number of Courses
Total
Challenge – department
prepared test
$50
$
Challenge – externally
prepared test
$20
$
Portfolio Assessment/MOU Agreement
No Charge
$
Department Org or Department ID Acct Code Amount
$
$
Total
Note: Form to be taken by student to LDCC Bursar’s Office for fee payment. Form to be returned by student to academic
department prior to the administration of an exam or submission of a portfolio/MOU assessment.
Step 3b: Fee Payment (to be completed by Payment and Disbursement Center if required)
Step 4: Report of Prior Learning Credit Earned (to be completed by department and submitted by department to Registrar)
Subject/
Catalog # Title Credits
Grade
Faculty Signature
Date
Department Chair
Signature
Date
Deliver to: LDCC Enrollment Services, 7500 Millhaven Road, Monroe, LA 71203
E-mail: adamabercrombie@ladelta.edu Phone: (318) 345-9003 FAX: (318) 345-9002 ||
