Please Print
Today’s Date: _________________________ Petition Request For _____________________ / ___________________
Term Year
Name: ____________________________________________________ G #: _________________________________
First Name Last name
Email: ____________________________________________________ Phone #: (______) _______________________
Submit this petition along with any supporting documentation to the Admissions & Records Office.
Your petition will be reviewed by the Academic Appeals Committee.
A copy will be returned to you (by US Mail) indicating approval or denial, and the reasons and/or the limitations
imposed by the Academic Appeals Committee.
Approval of this petition has no bearing on any decisions made regarding financial aid.
What is the specific and action you wish the Committee to consider? (Use a separate sheet if necessary)
Student’s Signature ________________________________________ Date ____________________________________
To be completed by Academic Appeals Committee
Petition is: Approved Denied Additional Information Needed
Rationale: _________________________________________________________________________________________
______________________________________________________________ _______________________________
Chair, Academic Appeals Committee Date
A&R 07/14
Gavilan College
5055 Santa Teresa Blvd
Gilroy, Ca 95020
Fax (408) 846-4940
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