Fillable Southern State Community College - Prior Learning Assessment Application

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Southern State Community College - Prior Learning Assessment Application

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Prior Learning Assessment
Application Form –
Page 1
of 2
NOTE: PLEASE COMPLETE THE FOLLOWING AND PAY $45 APPLICATION FEE
Instructions: A $45 non-refundable application fee must be submitted with this application. Please return page 1
with your application fee. Payment can be made in the business office in Hillsboro or in the campus drop box at any
campus location (remember to include Page 1 with the payment). Please attach page 2 with all supporting
documentation and forward to the appropriate Dean’s office. After your application review, if credit is awarded,
payment of $15 per credit hour for credits received must be made before credit will be posted to student's academic
transcript.
Applicant Name (Print) _________________________________________________________ ID# ___________________________
Address ____________________________________________________ City _______________________ State _____ Zip ___________
Email _____________________________ Home Phone ______________________ Day/Cell Phone _________________________
Signature of Applicant_________________________________________________________ Date__________________
Revised 09/15 ame
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Prior Learning Assessment
Application Form –
Page 2
of 2 (attach with all documentation)
Applicant Name (Print) ____________________________________________________________________ ID#_____________________________
Address________________________________________________________ City___________________________________ State_____ Zip_________
Email __________________________________ Home Phone__________________________ Day/Cell Phone _____________________________
Number of hours completed at SSCC_________ (must have completed at least 6 semester hours at SSCC to be
eligible) May earn maximum of 30 credit hours through Prior Learning Assessment. If credit is awarded,
payment of $15 per credit hour for credits received must be made before credit will be posted to student's
academic transcript.
Credit Faculty
Student Requests Course Number Course Title Hours Approval
__Example:___ ___ACCT 1104_ ___Principles of Accounting I_____________ __3__ _______
________________ __________________ ________________________________________________ _____ _______
________________ __________________ ________________________________________________ _____ _______
________________ __________________ ________________________________________________ _____ _______
________________ __________________ ________________________________________________ _____ _______
________________ __________________ ________________________________________________ _____ _______
________________ __________________ ________________________________________________ _____ _______
________________ __________________ ________________________________________________ _____ _______
________________ __________________ ________________________________________________ _____ _______
_________________ __________________ ________________________________________________ _____ _______
DOCUMENTATION REQUIRED: Students applying for Prior Learning Assessment must submit documentation that
will support their request for credit. Recommended documents are verification of length of employment and position
held, job description, letter of recommendation from supervisor (on company letterhead), certificates of completion for
non-credit courses or workshops, etc.
Signature of Applicant_________________________________________________________ Date__________________
- - - - - - - - - - - - - - - - - - - - - - Office use only - - - - - - - - - - - - - - - - - - - - - -
Based on the documentation presented by the applicant or the documentation requested by the committee, we the
undersigned make the following recommendation for Prior Learning Assessment Credit: (only one faculty signature
required per area)
_____________
___________________________________________ _______________________________________________________
Faculty Signature Date Faculty Signature Date
_____________
___________________________________________ ________________________________________________________
Faculty Signature Date Faculty Signature Date
_____________
___________________________________________ _________________________________________________________
Dean Date Vice President of Academic Affairs Date
Da
te forwarded to Records________ Memo Sent_______ Credit Posted_______
Revised 09/15 ame
** Please contact the SSCC Webmaster at webmaster@sscc.edu for
suggested updates or changes to this form **
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Southern State Community College - Prior Learning Assessment Application

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Completed 4 May 2020

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