Instructions
1. The student must complete date submitted, personal information, signature and check the appropriate line that
matches the request.
2. Student must explain why special permission is being requested in space provided, attach additional
information and/or documentation if necessary, and submits form to a Counselor/Advisor.
3. The Counselor/Advisor will enter Cumulative G.P.A., Total Hours Completed before submitting the Form to
the Dean of Enrollment Management & SS for approval. The Dean will forward the Form to the Vice
President of Academic Affairs & Student Services.
4. The Vice President of Academic Affairs & Student Services will render a final decision and return form to
Counselor/Advisor.
5. The Counselor/Advisor will notify regarding status of request. If approved, student is directed to obtain
yellow copy from Counselor/Advisor and submit original (white copy) to Admissions Office.
6. The Student will take the yellow copy of the Form to Admissions Office for execution of approved request.
Date Submitted: ________________ Semester: ______________ Major _____________________
Name: ______________________________________________ Student ID ________________
______________________________________________ Phone No. #_______________
Student’s Signature
Request permission for the following:
REQUIRES APPROVAL OF DEAN:
_____ Enroll in 19 or more hours (Fall/Spring) or 9 or more hours (Summer)
_____ Withdrawal after Last Day to Withdraw Deadline
REQUIRES APPROVAL OF DEAN & VICE PRESIDENT:
_____ Refund of tuition and fees beyond the Refund Policy timetable:
_____100% _____70% _____25%
_____ Waiver of $25 Registration Fee
_____ Drop after Last Day to Drop Deadline
Reason for request: (Attach additional information/documentation if necessary)
TO
BE COMPLETED BY COUNSELOR/ADVISOR:
Cu
mulative GPA _______ Total Hours Completed _______ _____________________________
Counselor/Advisor Signature
Approved Denied ____________________________________________ _______________
Dean of Enrollment Management & Student Success Date
A
pproved Denied ____________________________________________ ________________
Vice President for Academic Affairs & Student Services Date
White Copy: Admissions Office Yellow Copy: Student
Revised August/06 Galveston College is an EEO Institution
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