Coded By:_________
Term Coded:_________
Rev: 7-14-16
Please submit two copies of this petition; one will be returned.
Student’s name __________________________Advisor___________________ Date _______________
Local Address __________________________________________ Telephone ______________________
ID Number ________________ Program __________________ Email_____________________________
Please state concisely the requirement for which you seek an exception. Provide name and contact
information for individuals who are involved or would be affected by the decision (advisor, committee
members, others). Reference and attach additional documents, if needed.
Please state the reasons for this request:
Student’s Signature ___________________________________
Advisor Name/Signature:_____________________________________________Date _______________
� Approved � Not Recommended
Remarks: ____________________________________________________________________________
Department Head Signature: __________________________________________Date _______________
� Approved � Not Recommended
Remarks: ____________________________________________________________________________
Signature of Graduate Dean: __________________________________________Date _______________
� Approved � Not Recommended
Remarks: ____________________________________________________________________________
Petition to the Graduate Dean
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