COURSE REPETITION REQUEST
IMPORTANT: Please read all directions and fill out the form carefully. Review all your information to make sure that it is correct before
submitting to the Admissions and Records office. The purpose of this form is to repeat courses you PREVIOUSLY COMPLETED OR
WITHDREW. The final grade MUST BE POSTED before a request may be filed. After your registration appointment begins, submit
this form with an ADD/DROP CARD to Admissions & Records. Documentation required.
REASONS FOR REPEATING A COURSE
STUDENT INFORMATION
LAST NAME: ________________________ FIRST NAME: ________________________ MI: ____ STUDENT ID#:_________
EMAIL: ______________________________________________ PHONE: _______________________
SEMESTER (CURRENT): FALL WINTER SPRING SUMMER YEAR: ____________
COURSE HISTORY List the previous enrollments of the courses you intend to repeat provided in the space below.
CLASS
NUMBER
(EX: 30181)
COURSE TITLE
(EX: ANAT 1)
SEMESTER
(EX: SPRING)
YEAR
(EX: 2015)
GRADE
EARNED
(EX: D)
OFFICE USE ONLY
DECISION
APPROVAL
IF YES
CODE USED
YES NO
PETY PE3T
RPAL INCL
LMAN
YES NO
PETY PE3T
RPAL INCL
LMAN
YES NO
PETY PE3T
RPAL INCL
LMAN
YES NO
PETY PE3T
RPAL INCL
LMAN
I declare under penalty of perjury that I have reviewed and understood all information on this form as well as affirm that all
information on this form is true and correct.
STUDENT SIGNATURE: __________________________________________________________ DATE: _______________
Courses cannot be taken more than once EXCEPT under the following circumstances:
Earned a grade of A-F, NC (No Credit), P/NP (No Pass), W/EW (Excused Withdrawal) in the Spring 2020 semester
only.
Earned a substandard grade of: D, F, NC (No Credit), NP (No Pass) or received a grade of W (Withdrawal)
Received a passing grade more than three (3) years ago, but your program of study requires a more recent
completion. Documentation required.
Legally-mandated training requirement as a condition of continued employment. Official legal documentation
required.
Catalog Renumbering Issue Enrolling in a related but separate course, due to changes in course repeatability,
for example: SUBJ 1AD is now SUBJ 1, SUBJ 2, SUBJ 3 and SUBJ 4.
OFFICE USE ONLY
RECEIVED ON: ______________ STAFF SIGNATURE: _________________________________ STAFF INITIALS: ______
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