ACADEMIC REQUEST
This form is to be used in accordance with college policies that require special approval from a Division Chair and/or the
Vice President for Academic Services. The student making a request should describe the request below and then follow
the approval process on the reverse side as defined for the specific request.
Student Name: Student ID#:
Address: Phone Number:
Student Signature: Date:
DESCRIPTION OF REQUEST
The request should include the following:
1. A summary of the request.
2. Reason for the request.
ATTACH ADDITIONAL INFORMATION AS NEEDED.
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PLEASE SEEK APPROVAL AS APPROPRIATE FOR THE SPECIFIC REQUEST.
RECOMMENDATION FROM FACULTY/ACADEMIC ADVISOR (AS APPROPRIATE):
Date: Signature:
RECOMMENDATION/APPROVAL FROM ACADEMIC DIVISION CHAIR:
Date: Signature:
RECOMMENDATION/APPROVAL FROM VICE PRESIDENT:
Date: Signature:
Clear Form
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signature
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