PLEASE PRINT
Admissions and Records Petition
Time Conflict
Rec’d By _______
Date _______
Petition Refers to:
Fall 20______
Spring 20______
Summer 20______
____________________________________________________ ___________________________________
Student Name Date of Birth
____________________________________________________ ______________________________________
Mailing Address SCC Email Address
____________________________________________________ ______________________________________
City State Zip SCC ID#
COURSES IN CONFLICT:
REASON FOR PETITION: ____________________________________________________________________
INSTRUCTOR'S EXPLANATION OF HOW TIME WILL BE MADE UP AND DOCUMENTED BY THE
INSTRUCTOR (a record of these hours must be submitted to the Office of Admissions and Records at the end
of the semester):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
___________________________________ ________________________________
(Instructor’s Signature) (Date)
Approved Denied
___________________________________________________ ____________________________
Division Dean’s Signature Date
OAR: Approved Denied Date: By:
This petition will only be considered for approval if extenuating circumstances exist and all
requirements are met. Petitions are considered on a case-by-case basis.
Attendance documents received.
Form Distribution: White: OAR Yellow: Division Dean Pink: Instructor Goldenrod: Student
O\Admissions and Records\Forms\Petition\Approve Time Conflict 8.1.07
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