Name of student: Student ID:
Academic year:
Course Name and Number:
Required or Elective?
If elective, list alternative options if any:
Reason for taking online class:
Course Conflict What course?
Athletics Sport:
Full Class Do you have instructor consent?
If so please include instructor email or signature
Offered Only Online Are seats available?
Other Explain:
Additional Details:
Advisor Signature: Date:
Date Submitted to the Dept:
Permission number issued:
EOAS Initials:
Revision date: 3/4/15
Permission Number Request Form
Student Information
For Departmental Office Use Only
Course Information
Projected grad. date:
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