Distribution: Academic Dean/Registrar/Student
Student ID @_____________________ OR Social Security #_______________________
Name_________________________________________________________________________
(Last) (First) (MI)
Mailing
Address_______________________________________________________________________
(Street) (City) (State) (Zip)
Telephone ( )_____________ Major__________________________________________
Required Course: ___________ _______________________________________ ______
(Name & Number) (Course Title) (# credits)
Substitute Course: ___________ _______________________________________ ______
(Name & Number) (Course Title) (# credits)
Explanation of reasons for course substitution. Use reverse side if more space is needed.
I understand that if I am applying to graduate in this academic year, this form must be submitted to the Dean of
Academic & Student Affairs by November 1
st
for January graduation and April 1
st
for May graduation. It is my
responsibility to ensure that all approvals are received by the Registrar before December 1
st
or May 1
st
.
Student Signature____________________________________________________________ Date_____________
Submit form to your Academic Advisor or to the appropriate Faculty Member.
Request Approved: Request Denied:
____________________________________ ___________________________________
Faculty Member Date Faculty Member Date
_____________________________________ ___________________________________
Division Director Date Division Director Date
_____________________________________ ___________________________________
Dean of Academic & Student Affairs Date Dean of Academic & Student Affairs Date
Reason for denial (if applicable)____________________________________________________________________
_____________________________________________________________________________________________
REQUEST FOR COURSE SUBSTITUTION
Northwestern Connecticut Community College
Office of the Registrar
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