Name:________________________________________ ID#:__________

I request credit for the following course:

Course Number & Name:_____________________________________________

Taken at: Institution:__________________________________________

The upper level course which I successfully completed (Grade of C or Better) which validates this course is:

Course Number & Name:_____________________________________________

Semester Taken:__________________

Student’s Signature_________________________________ Date___________

Approved_______ Denied_______

Registrar’s Signature_________________________