Part I
Personal Information
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| Last Name: |
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| First Name: |
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| Middle Name: |
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| Mailing Address: |
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| E-mail: |
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| Area Code + Telephone #: |
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Part II
Application Basis
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Applying for Life Credits based on:
Select all check-boxes that apply |
Work Experience
Specialized Training
Military Training and/or Experience
Licensure and/or Certification
Workshops, Conferences, and/or Seminars Attended
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Type in the course designations for which you are applying for credit eg., BU340, BU455, BU480:
View List of Courses |
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Part III
Work Experience
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| Applying for Work Experience credits: |
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Current Employer:
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Current Employer Address:
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| Employer Area Code+Telephone#: |
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Current Length of Employment:
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Current Position:
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| Specialized on-the-job Training: |
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| If applicable, describe you job duties, responsibilities, & any specialized training received: |
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Length of Previous Employment:
| (years)
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Part IV
Military Experience
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| Current or Previous Military: |
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| Dates of Military Service: |
to (Use mm/dd/yy format)
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| Highest Rank Held: |
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| Military Occupational Code: |
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Describe your training and the type
of work performed in the military: |
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Part V
Licensure & Certification
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| Licensure or Certification: |
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| If applicable, select one: |
Licensure
Certification
Both Licensure & Certification
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| Type of Licensure or Certification: |
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| Dates of Licensure/Certification: |
to (Use mm/dd/yy format)
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Describe the work performed
under this licensure/certification: |
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Part VI
Workshops/Conferences/Seminars
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| Workshops/Conferences/Seminars: |
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| If applicable, select all that apply: |
Workshops
Conferences
Seminars
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| Number of Hours Attended: |
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| Describe the training attended: |
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Part VII
Community Service
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| Community Service: |
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| Number of Hours of Service: |
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| Contact Person(s): |
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| Describe your responsibilities & duties along with a brief over-view of the organization worked with: |
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Part VIII
Professional Authorship
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| Professional Authorship: |
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| If applicable, select all that apply: |
Book Published
Professional Publications/Articles/etc.
Professional Script/Databases/etc. (Programming)
Other - explain in text box below
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| If "other" marked above, comment here: |
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| If applicable, title of book or publication: |
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| Year Published: |
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| If applicable, who/where published: |
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| If applicable, the ISBN#: |
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| Hours for completion: |
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| Describe in general what you authored : |
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Part IX
Student Service Agreement
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| Student Service Agreement: |
View Student Service Agreement
I accept all terms and conditions listed herein.
I do not accept all terms and conditions listed herein.
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Comments or Requests
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| Comments or Special Requests: |
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Please click the "Submit Form" button.
Note:
Upon receipt of the $50.00 processing fee,
your assessment will be processed within
5 business days from the date all verifying
documents are received by Canyon College.
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