If you are interested in enrolling in the Portfolio Development for Prior Learning course at FCCJ, please complete the information below. You may submit the form by: Fax: 904-632-5092, or mail: FCCJ Accelerated College Office, 601 W. State Street, Jacksonville, FL 32202. If you received this by email, you may return it to slynn@fccj.edu.
CONTACT INFORMATION
Last Name: Social Security Number:
First Name: Middle Name:
Street:
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City: State: Zip:
Phone: ( ) E-mail:
Area Code
MILITARY EXPERIENCE
From ____________ to ____________ __________ ___________________________
Service Dates Grade/Rank Military Title/Rate Duties:_____________________________________________________________________________ __________________________________________________________________________________
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PROFESSIONAL EXPERIENCE
From To Company Name Position Responsibilities
JOB 1 _________ __________ _______________________ ___________ _____________________
JOB 2 _________ __________ _______________________ ___________ _____________________
JOB 3 _________ __________ _______________________ ___________ _____________________
JOB 4 _________ __________ _______________________ ___________ _____________________
OTHER EXPERIENCE
List any special educational experiences you have had, such as independent study projects, study abroad, any school or community projects, volunteer, sports or religious activities. Include any special recognition that you have received for these activities. If you hold professional, business or industrial related licenses, certificates/credentials, or can provide relevant information, please list them.
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EDUCATION
1. List all credits or degrees earned with dates and names of institutions. Please circle NONE if you have never attended college. NONE
Institution Name Location (City/State) Dates of attendance Credits earned
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2. Have you attended FCCJ’s New Student Orientation? YES NO
3. List the month and year you last met with an FCCJ academic advisor: _________________________
4. Current program of study at FCCJ: ___________________________________________________________
NAME PROGRAM NUMBER
5. Using FCCJ course numbers and titles, list the course(s) for which you will request portfolio evaluation.
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PROGRAM ADVISOR NOTES
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