Prior Learning Assessment- Student Intake Form

Please ONLY fill this form out after speaking with the PLA Office and being APPROVED to challenge.

If you are challenging multiple courses, please fill out this form for each class you are challenging.

Your Name: Your Name: * First Last
UIN: *
Must be 8 characters. Currently Entered: 0 characters.
ODU E-Mail Address: *

Confirm ODU E-Mail Address: *
Course Prefix (CS, MGMT, HMSV, etc.) *
Course Number (101, 311, 312W, etc.) *
Number of Credits for Course: *
Must be between 1 and 2 digits. Currently Entered: 0 digits.
Challenge Method: *
Challenge Cost: * $ Dollars . Cents
Faculty Assessor: *
STUDENT RESPONSIBILITY STATEMENT

1. General Responsibility: I understand that it is my responsibility to ensure that the credits I earn through a departmental examination are applicable to my degree program.

2. Financial Responsibility: I understand that tuition charges for departmental exams through Prior Learning are subject to the University’s tuition policy and that the fee is non-refundable and not subject to financial appeal. Billing is done after submission of this form to the Prior Learning Assessment Office.There is a 10% late payment penalty fee after 30 days. There is a 33.33% late payment penalty after 60 days. I also understand that no financial aid can be used to cover the cost of the Challenge.
Student Signature: *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Prior Learning Assessment- Student Intake Form

Prior Learning Assessment- Student Intake Form

STUDENT RESPONSIBILITY STATEMENT