Fillable PETITION TO UNDERGRADUATE EXCEPTIONS COMMITTEE INSTRUCTIONS ON OTHER (Kutztown University of Pennsylvania)

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PETITION TO UNDERGRADUATE EXCEPTIONS COMMITTEE INSTRUCTIONS ON OTHER (Kutztown University of Pennsylvania)

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PETITION TO UNDERGRADUATE EXCEPTIONS COMMITTEE INSTRUCTIONS ON OTHER SIDE
KUTZTOWN UNIVERSITY OF PENNSYLVANIA - Kutztown, PA 19530
Student ID #
Name: Please choose Mr Ms
Telephone # Advisor
Address City State Zip Curriculum/Major
Are you a student athlete? Please choose
YES NO
St
udent Signature Date: E-mail:
REQUEST
REASONS (Attach additional sheets as necessary.)
REVIEW/STATEMENTS and SIGNATURES
* REQUIRED ON ALL REQUESTS REQUIRED ONLY IF OTHER DEPARTMENT OR FACULTY INVOLVED
Support: Yes No
Chairperson (Please Print) _____________________________________
Signature & Date *
Support: Yes No
Faculty Name (Please Print) _________________________________________
Signature & Date
Support: Yes No Support: Yes No
Advisor Name (Please Print) Faculty Name (Please Print)
Advisor Signature & Date * Faculty Signature & Date
Do you receive Financial Aid? If yes, please ask for Financial Aid form to accompany this
petition.
INSTRUCTIONS FOR PETITION TO THE
UNDERGRADUATE EXCEPTIONS COMMITTEE
(PETITION ON REVERSE SIDE)
Provide all information requested following the instructions below. THE PETITION MUST BE COMPLETE, CLEARLY STATED AND
LEGIBLE OR IT WILL BE RETURNED TO THE PETITIONER. The petitioner is responsible for obtaining all recommended statements
and signatures.
1. Complete the following sections: Name, Address, Daytime Telephone Number, Email Address, Student ID Number, Advisor,
Curriculum and Major. Correspondence will be sent to the address provided on the petition.
2. Clearly state the request. Reference to a course MUST include the course prefix, number, section, 4 digit class number and complete
title.
3. State the reason(s) for the petition. All relevant information should be provided. All information provided is considered confidential.
4. The Committee REQUIRES that you seek WRITTEN SUPPORT from the DEPARTMENT CHAIR OF YOUR MAJOR, and YOUR
ADVISOR ON ALL PETITIONS. For requests concerning ATTENDANCE it is REQUIRED that you seek WRITTEN SUPPORT
FROM INSTRUCTOR(S) involved.
5. Committee decisions may negatively impact financial aid packages. It is the student’s responsibility to contact the Financial Aid
Office. If you receive (d) FINANCIAL AID, you MUST have the Financial Aid Consultation Form completed by a Financial Aid
Consultant. Petitions will not be accepted without a completed form.
6. Submit the completed petition to the Registrar's Office, 115 Stratton Administration Building, Kutztown University, Kutztown, PA
19530. Completed petitions may also be faxed to 610-683-1586.
7. The petitioner will be notified in writing of committee action.
Rev. 05/17 SAM
Financial Aid Consultation Form to Accompany
Undergraduate Exceptions Committee Petition
________________________________________________ __________________________________________ ____________________________________________
Name Student ID # Daytime Telephone Number
I a
m submitting an Undergraduate Exceptions Committee Petition that may affect my financial aid for the _______________ semester.
I was informed and understand how this request may affect my financial aid.
C
omments from Financial Aid Representative:
_____________________________________________________ _____________________
Financial Aid Representative’s Signature Date
________________________________________________
___________________
Student’s Signature Date
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PETITION TO UNDERGRADUATE EXCEPTIONS COMMITTEE INSTRUCTIONS ON OTHER (Kutztown University of Pennsylvania)

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Completed 22 August 2020

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