Students wanting to take a proficiency examination must receive permission from the Department
Chairperson. A $50.00 fee will be charged for each proficiency examination prior to the student taking
the examination.
RLR:prc/“X” Credit Form/10-08-2015
FOR OFFICE USE ONLY
Date received:_____/_____/_____ Date completed:_____/_____/_____
Completed by (Please print - Required):__________________________________________________
Signature (Required):__________________________________________________________________
TO BE COMPLETED BY STUDENT (PLEASE PRINT):
Name:______________________________________ __________________________________ ________
LAST FIRST MI
CougarID Number: ________________________________
Program of study:____________________________________________________________________________
Street Address:______________________________________________________ Apt Number:_____________
City:______________________________________________ State:__________ ZIP Code:_____________
Daytime Telephone: (_____)_____________________ Evening Telephone: (_____)_____________________
Student Signature (Required):__________________________________________ Date: ____/____/____
TO BE COMPLETED BY THE ACADEMIC DEPARTMENT:
COURSE CREDIT CHAIRPERSON SIGNATURE DATE
NUMBER HOURS
______________ _______ _________________________________________ ____/____/____
______________ _______ _________________________________________ ____/____/____
______________ _______ _________________________________________ ____/____/____
______________ _______ _________________________________________ ____/____/____
PLEASE SUBMIT THIS FORM TO THE APPROPRIATE ACADEMIC DEPARTMENT FOR REVIEW.
A
LL FIELDS MUST BE COMPLETED FOR PROCESSING.
P
LEASE ALLOW 5 (FIVE) BUSINESS DAYS FOR PROCESSING.
REQUEST FOR PROFICIENCY (X) CREDIT
