__________________________________
Date

__________________________________
Student's Name

__________________________________
Address

__________________________________
City, State Zip

__________________________________
Social Security Number
 
 

Request is made for a course substitution in the

__________________________________________________ curriculum.

__________________________________
Course title and number to we waived

__________________________________
Course title and number to be substituted
 
 

__________________________________
Counselor/Advisor                    Date

__________________________________
Academic Dean                        Date

__________________________________
Registar                                    Date