Revised 1/24/20
Request to Waive or Substitute Course
*Indicates required field
Student Name* ____________________________________________________________________________________
Student ID/SSN* _____________________________________________ Phone* _______________________________
Address* _________________________________________________________________________________________
Street City State Zip
Petition for graduation on file? Yes No Program Name _____________________________________________
APPROPRIATE SIGNATURES MUST BE OBTAINED BEFORE SUBMITTING FORM TO GRADUATION SERVICES
Request to substitute/waive is*: Approved Not Approved
Criteria for approval of request ________________________________________________________________________
____________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Department Chair Signature* _____________________________________________ Date _______________________
Dean Signature* _______________________________________________________ Date _______________________
Return completed form to:
Mailing Address: Clackamas Community College, Graduation Services, 19600 Molalla Ave, Oregon City, OR 97045
Location: Graduation Services, Roger Rook Hall Lobby
Email: gradservices@clackamas.edu
For questions, contact:
Phone: 503-594-6651
Email: gradservices@clackamas.edu
I WISH TO MAKE A FORMAL REQUEST TO*:
Waive the following course requirement.
Course Number _________________________ Course Title ____________________________________________
Substitute the following course for a required course.
Required Course Number _________________________ Course Title _____________________________________
Substitute Course Number _________________________ Course Title ____________________________________
My reason for requesting this waiver/substitute is __________________________________________________
_____________________________________________________________________________________________
I understand that, if granted, this request does not reduce the number of credits required for my degree or
certificate.
Student Signature* ______________________________________________________ Date ___________________
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