S:\Continuous Improvement Projects\Academic Petition\Academic Petition form 120811.docx Page 1 of 2
Term: Summer Fall Spring Year: _______________
Name: ____________________________________________________________________________________
Last First Middle
Permanent Address:__________________________________________________________________________
Street City State Zip
Home Phone: ____________________________ Cell Phone: ______________________________________
Personal Email Address: _____________________________________________________________________
Any student currently enrolled in Anoka Technical College may use the Academic Petition Form to request a
waiver to the academic policies of the college.
Course pre-requisite
Waive program requirement
Credit requirement for program
Repeat course (beyond college policy)
Repeat Accuplacer ____________________
Waive Adult Basic Education refresher-prior
to repeating Accuplacer test ____________
This form is NOT to be used to request
a grade change, see course instructor.
Students petitioning will need to provide a transcript from non-MnSCU institutions, and purpose or reason for
the petition (use the space below to define your request). The petition and documentation will then be
forwarded to the appropriate faculty member(s) and then the Academic Dean for evaluation. Allow 10-15
business days for results/determination (allow for additional processing time during summer and semester
breaks) on the Academic Petition. If the student disagrees with the decision made by the Academic Dean they
may appeal to the Vice President for Academic and Student Affairs.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
I understand that if I have not followed the instructions on this petition or if I have not attached
the proper documentation, my petition cannot be processed. The statement and documents that
I have attached are true and accurate to the best of my knowledge. When submitting this
document electronically, my typed name will serve as my signature.
Student Signature: _________________________________________________ Date___________________
MAIL, FAX OR EMAIL FORM TO:
Anoka Technical College, ATTN: Academic Affairs 1355 W Highway 10, Anoka, MN 55303
Fax (763)-576-4715 AcademicAffairs@anokatech.edu
Date: ________________________________
Student ID: ___________________________
Academic Program: _____________________
Academic Petition
S:\Continuous Improvement Projects\Academic Petition\Academic Petition form 120811.docx Page 2 of 2
When the Academic Petition has been finalized, the Academic Affairs office will make copies and
distribute one copy will be mailed to the student, the other copies to the faculty/staff member(s). The
original Academic Petition will be stored in the Student Record in the Records and Registration Office.
OFFICE USE ONLY
Faculty/Staff members
(Please print your Name, Department and your recommendation in the space below)
Approved Not Approved Approved with conditions
Name: __________________________________________ Department: _____________________________
Comments: ______________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Signature ___________________________________________ Date ________________________________
Approved Not Approved Approved with conditions
Name: __________________________________________ Department: _____________________________
Comments: ______________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Signature ___________________________________________ Date ________________________________
Approved Not Approved Approved with conditions
Name: __________________________________________ Department: _____________________________
Comments: ______________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Signature ___________________________________________ Date ________________________________
_____________________________________________________________________________
Academic Dean
Approved Not Approved Approved with conditions
Decision and comments:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Signature: ________________________________________ Date: __________________________________
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