UNIVERSITY OF PITTSBURGH \ FORM INSTRUCTION GUIDE



FORM TITLE:              CREDIT BY COURSE EXAMINATION
NUMBER:                  FORM 0143
PROCEDURE:               09-04-06




TO BE COMPLETED BY THE STUDENT OR THE STUDENT'S ACADEMIC CENTER:

                      STUDENT INFORMATION


    1.    Student Social Security Number

    2.    Student Level - Check One

    3.    Year  of  the  term in which test is to be administered
          (Format YYYY)

    4.    Student Name (Last/First/M.I.)

    5.    Student Address (City/State/Zip Code)

    6.    Name of Academic Center in which student is enrolled

    7.    Signature of student

                       COURSE INFORMATION



    8.    Number of Credits

    9.    Subject Area

   10.    Four-digit Course Number

   11.    Course Title


                  ACADEMIC CENTER AUTHORIZATION


   12.    Signature  of  Academic  Dean  (or  designee)  of   the
          Academic Center in which the student is enrolled

   13.    Two-digit  Academic Center Code of the Academic  Center
          in which the student is enrolled

   14.    Date signed

   15.    Signature  of  the Academic Dean (or designee)  of  the
          Academic Center administering the test and date




TO BE COMPLETED BY THE ACADEMIC CENTER OFFERING THE COURSE:

                        TEST INFORMATION


   16.    Date and Time test is to be administered

   17.    Test Location (Building and Room Number)


_
TO BE COMPLETED BY THE INSTRUCTOR ADMINISTERING THE EXAMINATION:

   18.    Results:  Check one to Indicate "Pass" or "Fail" Grade

   19.    Signature of Instructor


TO BE COMPLETED BY THE CASHIER:

   20.    Signature of Cashier Receiving Payment and Date

   21.    Amount of Payment


TO BE COMPLETED BY THE REGISTRAR'S OFFICE:

   22.    Date credit is posted to the student's transcript

   23.    Initials of Registrar's Office processor

   24.    Initials of individual verifying the entry