CPCC Credit by Examination (CBE) Course Request Form
Date:
Student ID #
Term
First Name
Year
MI
Address
Last Name
City
State
Student Email
ZIP
Student Phone:
Program Name
and Code
Course Prefix
and Number
Course Name
Rationale for
Request
Registration Required?
Test Fee
Yes
$
If Yes – Registration Confirmed?
NOTE: Fees for Credit by Examination are NON-REFUNDABLE.
Program Chair
Date
Cynthia Brunson
Division Director
GL Account #
No
X
Print Name
Signature
Print Name
Signature
Date
Keith Henn
0
1
-
3
1
9
-
0
0
-
4 9
4
9
0
0
-
3
2
5 2
6
$
TEST FEE PAYMENT INFORMATION
This section to be completed by the Cashier’s Office and returned to the Student
Check #
Amount
Card
Type
$
Confirmation
#
Visa
MC
Am
Exp.
$
Processed by
Date
This section is to be completed by the Course Instructor and forwarded to Student Records
Test Date
Calculator
permitted?
Location
Yes
No
Time In
Test Score/Grade
Time Out
Pass
Credits
Earned
Fail
Test Administrator
Program Chair
Division Director
Date
Print Name
Signature
Print Name
Signature
Print Name
Signature
Date
Cynthia Brunson
Date
Keith Henn
This section is to be completed and kept on file by Student Records – ORIGINAL COPY ONLY
Processed by
CBE Test-Out Form
Date
Updated: 10-2012