Credit by Examination Request Form
Instructions to Students:
To officially receive credit for previous training or experience, you should consult your advisor or the PLA Coordinator to
discuss the feasibility of pursuing the credit. Students should complete steps 1, 2, and 3 (if applicable) and then submit
form to their advisor.
NOTE: Requested credit must meet a student’s degree requirement (see student’s Degree Audit).
Step 1: Student Information Section (Must be completed prior to assessment)
Name: ____________________________________________________ ID or SS#: _____________________________
Address: _____________________________________ City: ____________________ State: _______ Zip: ________
Step 2: Assessment Requested (A separate form must be submitted for each course)
Course for which credit is desired: ______________________ ______________________________________________
Course Number Course Title
Type of Assessment Fee
License/Certificate
Official certification from a previously assessed and accepted source
No Fee
(Go to Step 4)
Credit by Departmental Exam
Departmental exam constructed and graded by an ANC instructor
$20 per credit hour
(Go to Step 3)
Step 3: Business Office Section (Must be completed prior to assessment)
Exam Assessment Fee: ____________ Receipt Number: _________ Date Paid: ________ Received by: ______
Step 4: Instructor/Division Chairperson Section
Approved Credit Recommended for: ____________________ ______________________________________________
Course Number Course Title
Step 5: Signatures (Required if approved in Step 4)
______________________________ _____________ ______________________________ ____________
1. Instructor (if applicable) Date 3. Chief Academic Officer Date
______________________________ _____________ ______________________________ ____________
2. Division Chairperson Date 4. Registrar Date
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