Experiential Learning Petition

Experiential Learning Petition
Full Name*

First NameLast Name
Major*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
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Intended Term Of Enrollment*
Academy Course Number & Title*
Academy Course Number & Title
Academy Course Number & Title
Academy Course Number & Title
Academy Course Number & Title
*Grades that are earned though experiential earning are denoted P for Pass.
Enter the message as it's shown*
*FOR OFFICE USE ONLY* - do not fill out
#1 Credit Hours & Assigned Faculty
#2 Credit Hours & Assigned Faculty
#3 Credit Hours & Assigned Faculty
#4 Credit Hours & Assigned Faculty
#5 Credit Hours & Assigned Faculty
Approved by:
Dean of Academic Affairs or Designee
Date

MonthDayYear
Should be Empty:

*FOR OFFICE USE ONLY* - do not fill out