Student ID Student’s Last Name Student’s First Name
Year/Term Course Name & No Section No Name of Instructor
My signature signifies that I have read the instructions and have adhered to the published deadlines to
select this option. I agree to sign and return this form to the Admissions & Records office by the Pass/No
Pass deadline (each section has a specific deadline – as verified against the deadline within the MC
Portal). If mailing, faxing, or emailing a scanned form, it must be received by or before the individual
section’s deadline.
By signing and submitting this form,
I understand that the Pass / No Pass option is not reversible for any reason and after submitting
this form to the Admissions & Records office I may not change my mind at a later date and request
a letter grade.
I understand the Pass / No Pass option policy and I elect to receive a P or NP grade in the course
section(s) that I have identified on this form.
I understand that it is my responsibility to verify whether or not the course is offered with a
Pass/No Pass option by checking with the instructor, the current college catalog or conferring with
a Mission counselor.
I understand that it is my responsibility to verify if the Pass/No Pass option is available within my
major degree work or if it is transferable to a four-year college or university.
_______________________________________________ __________________________
Student Signature Date
Instructions for selecting the Pass / No Pass Grading Option
As the student it is your responsibility to:
1. Pick up the form from the Admissions & Records office, or download it from MC Portal Admissions
& Records page, complete, and sign it;
2. Return the completed & signed form by the deadline posted for your section available on the MC
Portal Admissions & Records page any of the three ways below:
a. By Email: Scan and attach form to email. Send to
b. By Fax to: (408) 980-8980
c. In-Person: Admissions & Records Office during posted open hours
Pass / No Pass Grade Option Request
To use this form, you must be currently enrolled in a credit course
that has a Pass / No Pass grading option.
Admissions & Records Use Only: Year/Term ______________________
Date Received: __________________ Date Entered: ______________________ By: ________________________________
Please print clearly in ink.
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