I request that_________________________________,   _________________________________
                                   Name of Student                                             Social Security Number
 
 

grade exclusion be awarded for

______________________   Semester  ______________________   Semester  ______________________   Semester

___________________Year  ___________________Year  ___________________Year

Student is presently enrolled:    Yes_______  No_______

Comments:______________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________
 
 

_________________________________________________ Signature of Advisor/Academic Dean _________________________________________________ Signature of Vice President for Instruction

_______________________  Date _______________________ Date

Note: Request can be made after a period of at least two years and evidence of noticeable improvement.

** Please attach student’s complete transcript to this form.
 
 

White copy Vice-President’s Office

Yellow copy Records Office

Pink copy Counseling Office

Gold copy Student copy