Jackson Community College - Application for Credit by Examination

Student Information (Please Print)

Name____________________________________ Social Security No.___________________

Address____________________________________________________________________

Telephone Home Phone (             )________________ Work Phone (          ) _________________

Course Information
 Course Prefix and No. ___________ Course Name_______________________ Credits ____

Date of Examination __________________ Grade Earned _____________

Have you ever been enrolled in this course at JCC? __No __Yes Semester/Year _________

Department Approval
 Faculty Evaluator ____________________________ Signature___________________________

Approved by Department Chair__________________Signature___________________________

Approved by Dean ___________________________Signature___________________________
[Department Chair will forward completed document to the Dean for approval; the Dean’s office will forward to the Cashier]

Cashier
The student upon successful completion of the Credit will pay fifty percent (50%) of the current "in-district" per credit hour rate by Examination.

Amount Paid ____________ Date ____________

Processed by Cashier _______________________ Receipt No. __________

Signature___________________________

Copies: __ Registrar __ Department Chair __ Cashier

Please read the following:
 1.  Upon successfully completing the Credit by Examination test, the student must pay the tuition assessed in order to have the credit posted.
2.  The faculty evaluator grades the student’s examination and forwards the completed Application for Credit by Examination form to the Registrar for processing.
3.  The Registrar will issue a student transcript reflecting the credits earned.
4.  The student understands the five points outlined on the first page of the application.

I have read and understand the information on this form for Credit by Examination.

Student Signature_____________________________________    Date_________________________

Date transcript mailed ___________ Clerk’s initials ___________