Admissions & Records
College of the Siskiyous, 800 College Ave., Weed, CA 96094
Phone: (530) 938-5500 - Fax: (530) 938-5367 Email:
Course Repeat
AP 4225; Title 5 - 55230
Last Name: First Name: MI:
Date of Birth: Student ID#: S00 or SSN:
COS Email: Phone:
Mailing Address:
City: State: Zip Code:
I hereby request permission to repeat the following course(s):
Course Number (i.e. ENGL 1001)
Course Title (i.e. English Composition)
Course was originally completed in: Fall Spring Summer Winter Grade:
Course to be completed during: Fall Spring Summer Winter
If course has been repeated at another school, please indicate where.
(Official copy of transcript must be submitted)
Indicate reason for repeat (check box)
I need to repeat course since a significant lapse of time has occurred since the course was originally taken and an
update of information is needed. Repeated course will not be counted in Grade Point Average (GPA) calculations
(Title V, Section 55763).
Please specify how repeating course work will be of assistance to you:
I need to repeat course to fulfill the requirements of a legally mandated training requirement for paid or volunteer
employment. Credit for each repeat will be computed in student’s GPA.
Signature: Date:
Office Use Only
Official Signature Date
Approved Denied Entered into system: