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Somerset Community College
REQUEST FOR SPECIAL EXAM
I request the opportunity to take a challenge examination in:
Course Title: ___________________ Fee: Lab $40.00 Lecture $20.00
Course Number: _____________________Receipt NO._____________
My request is based on the following reasons:
Student Signature: ____________________________________________
Student ID: ________________ Phone Number: ________________
Request granted: ____ Request denied: ____
Instructor’s Signature: ________________________ Date: ____________
Program Coordinator’s Signature: ____________________ Date: ___________
Department Chair’s Signature: _______________ Date: _________
Instructors Report for Exam
The grade in this class to be recorded as Credit by Examination is:
Circle the appropriate grade: P F
Date: ____________ Signature:_______________________
Registrar’s Notes
Subject_________________ Academic Plan:____________
Program Plan____________ Term__________
Recorded on student’s record (date) __________by___________________
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