UNIVERSITY OF ILLINOIS AT SPRINGFIELD
Office of Records and Registration Student Petition
Please complete, print (see "Print Form" button above), acquire the appropriate signatures, and return this form to the Office of Records and
Registration, University Hall, One University Plaza, MS UHB 1076, Springfield, IL 62703-5407. Forms are processed on a weekly basis. Please
be sure to carefully complete all information prior to printing the document.
Last Name First Name
UIN
UIS Email*
Daytime Phone
Records (217) 206-6709 Degree Audits (217) 206-8216 Registration (217) 206-6174 Graduation (217) 206-7730
For Office Use Only
Processed By:
Date:
Notifications (sent via official UIS Email by the Office of Records and Registration):
Original:
Student
Type of Request
Adviser
Current Semester
I base this request on the following rationale: (Please feel free to attach additional documentation)
Student Signature
Adviser
Department Chair
Dean/Associate Dean
Vice Chancellor for Academic Affairs/
Associate Vice Chancellor for Academic Affairs
Instructor Date
Date
Date
Date
Date
Approve Deny
DenyApprove
DenyApprove
DenyApprove
DenyApprove
See Attached Notes
See Attached Notes
See Attached Notes
See Attached Notes
See Attached Notes
Check all that apply
Adviser Dean Instructor
Date
Approvals (Printed Name / Signature)
Program VCAA
Permanent File
Permanent File
05/27/2015
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/
/
/
/
Curriculum Type: Curriculum
@uis.edu
*You MUST enter your
official UIS Email address