Submit completed form to the Dean of Learning Support (D108) or fax it to 217-351-2595
Parkland College
PETITION FOR EXCLUSION OF INDIVIDUAL GRADES FROM ACADEMIC RECORD
STUDENT INFORMATION (please print clearly or type)
Last name ___________________________________________ First name _____________________________
Student ID ___ ___ ___ ___ ___ ___ ___ Daytime phone (________)___________________________
Street Address _______________________________________________________________________________
City, State, Zip _______________________________________________________________________________
PLEASE PROVIDE THE INFORMATION REQUESTED BELOW:
My current program of study:
____________________________________________________________________________________________
My previous program of study:
____________________________________________________________________________________________
List of courses to be excluded:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Student’s signature _______________________________________________ Date _______________________
FOR ADMINISTRATIVE USE ONLY
Approved Denied Pending (see comments) Effective Date: ___________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Signature _______________________________________________________ Date _______________________
Please note that only grades of F or D earned
in courses which were required for graduation
under a student’s previous enrollment in a tra
nsfer or occupational program which are not
required for graduation under the student’s
current occupational program are eligible for
exclusion. For further information, please cons
ult the Parkland College Catalog or see an
academic advisor, counselor, or the Dean.
click to sign
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