Submit completed form to the Dean of Learning Support (D108) or fax it to 217-351-2595
Parkland!College!
REQUEST!FOR!EXCLUSION!OF!ACADEMIC!RECORD!
TO!THE!STUDENT!
You$may$request$exclusion$of$prior$academic$records$only$after$an$absence$of$at$least$two$years.
You$must,$upon$your$return,$complete$15$credit$hours$at$Parkland$within$two$years$before$submitting$this
request.
Approval$of$exclusion$means$that$grades$in$the$earlier$period$will$be$excluded$from$the$computation$of$your
grade$point$average.$$The$grade(s)$and$course(s)$will$contin ue$to $be$listed $on $you r$pe rm an en t$aca de m ic
record$and$o n$an y$tran scrip t.$$Cred its$earn ed $in$the$earlier$period$remain$valid.
Exclusion$will$apply$to$all$of$the$credits$attempted$or$completed$during$the$period$of$exemption.
STUDENT!INFORMAT ION$(p lea se 'print'cle arly'o r'type )$
Last$ name$___________________________________________$$First$name$_____________________________$
Student$ID$$___$$___$$___$$___$$___$$___$$___$$$Daytime$phone$$(________)___________________________$
Street$Address$______________________________________________________________________________$
City,$State,$Zip$_____________________________________________$Email:$____________________________$
PERIODS!OF!ENROLLMENT/NON>ENR OLLMEN T!
Circle'appropriate'semesters;'fill'in'years'in'provided'blanks.'
Period$to$be$excluded:$ $$$$$$$$$$FROM:$$Fall$/$Spring$/$Summer$$Year$_____$$$TO:$$$Fall$/$Spring$/$Summer$$Year$_____$
Period$not$attending:$$$ $FROM:$$Fall$/$Spring$/$Summer$$Year$_____$$$TO:$$$Fall$/$Spring$/$Summer$$Year$_____$
Period$of$latest$enrollment:$$$FROM:$$Fall$/$Spring$/$Summer$$Year$_____$$$TO:$$$Fall$/$Spring$/$Summer$$Year$_____$
RATIONALE:!!Give%reasons%for%your%request%and%attach%supporting%documentation.%%If%preferred,%you%%may%
attach%a%typewritten%statement%of%your%rationale.'
____________________________________________________________________________________________$
____________________________________________________________________________________________$
____________________________________________________________________________________________$
____________________________________________________________________________________________$
$$Check$here$if$supporting$documentation$Is$attached$
Student’s)signature$_______________________________________________$$Date$_______________________$
FOR!ADMINISTRATIVE!USE!ONLY!
!!Approved$$$$$$$Denied$$$$$$$Pending$(see$comments)$$$$$$$$
____________________________________________________________________________________________$
____________________________________________________________________________________________$
____________________________________________________________________________________________$
Signature)_______________________________________________________$Date$_______________________
The$original$copy$remains$in$the$Dean's office. Student should keep a copy for their records.
$A$copy$will$be$filed$in$the$student’s$permanent$record$in$Admissions$and$Records.
