Today's Date

Last Name  

First Name  

 MI                

Former Name, if applicable

Daytime Phone

E-Mail Address

Male     Female

Connect ND Student Emp ID#   or *Social Security Number

*Disclosure of your Social Security number is voluntary. Social Security numbers are used as individual identification numbers for record keeping and administrative purposes. Failure to provide either a Social Security number or Connect ND student EMP ID # may delay administrative services and processing.

Class for which you are requesting attached credit (check one only):

EC 236 Social/Emotional Development & Guidance (4 credits) -- Modules 8, 9, 10, 14, 15

EC 209 Learning Environments for Children (3 credits) -- Modules 1, 2, 3

EC 233 Pre-K Methods & Materials (4 credits) -- Modules 4, 5, 6, 7

EC 222 Administration & Leadership in ECE (3 credits) -- Modules 11, 12, 13

Module completion (check one):

Modules for the designated class have been completed.
Modules for the designated class have been started but are not yet complete.

Name of military facility where training occurred:

Name of trainer:

Phone number of trainer:

E-mail address of trainer:

Documentation of Module Completion: Ask your trainer to send copies of Air Force form, AFINT 1098, for each module connected to the class for which attached credit is requested. These documents should be mailed to:

Caregiver Program Advisor, MSU-Bottineau, 105 Simrall Blvd, Bottineau, ND 58318

Fee Payment: Students applying for articulated credit for classes in the Child Caregiver Services program must pay an attached credit fee of $30 per credit by the Fee Payment date listed on the campus Academic Calendar.

Mail checks or money orders to:

Business Office, MSU-Bottineau, 105 Simrall Blvd, Bottineau, ND 58318.

To pay by credit card, call 701-228-5430 or pay online using Connect ND > Student Self Service.

Course Assessment & Grading: Students must complete a course-related assessment from MSU-Bottineau before the end of semester. This assessment, along with percentages earned on knowledge and competency assessments for the Department of Defense Early Childhood Training Modules will be used to calculate a grade for the course.

*Signature:    By checking this box, you have created an electronic signature as legally binding as your hand-written signature. Also, by checking this box, you acknowledge that you understand the attached credit fee payment policy, course completion expectations, and drop/withdraw policies. You MUST check this box for the application form to be completed. If you have not received confirmation of your registration within three business days, please call Student Services at 1-800-542-6866.