Student Petition
Submit completed form to the Admissions & Records Office
P
LEASE LIST ALL COURSES RELATED TO THIS PETITION. REQUESTS FOR A CHANGE OF GRADE MUST BE SENT TO THE
INSTRUCTOR.
Semester / Year Course Name (eg: ENG 1A) CRN (e.g., 94321)
FOR THE COURSES LISTED ABOVE, I AM REQUESTING THE FOLLOWING:
Student’s justification for request: (Please use a separate sheet, if necessary)
Date:
Student Signature:
Counselor Rationale (Required for all requests except Fees Waived.)
Transcripts have been reviewed and attached.
Counselor Name (please print)
Date:
3000 Mission College Blvd., Santa Clara, CA 95054
A & R
1.08.2020
Comments:
Student Petition Committee Signature:
Date:
Mission College ID #:
Email Address:
Telephone:
Name:
Last
First
M.I.
Address:
Street
City State Zip
FOR OFFICE USE ONLY
Rec’d By:
Date:
Fees Waived
Supporting documentation required after 20% of class
meetings. (Smartpass, Campus
Center, and Web Services fees not waivable)
Drop Without “W” with Refund
Supporting documentation required
after 20% of class meetings.
Course Repetition (4th time and/or Passing Grade received)
Counselor rationale required including revised CEP.
Drop With “W”
Supporting documentation required after 75% of class meetings.
Approved Denied
Approved
Denied
Any request below must meet with Counselor before submitting:
I AM CURRENTLY RECEIVING FINANCIAL AID AND UNDERSTAND THAT CHANGES TO MY RECORD MAY
REQUIRE REPAYMENT OF FUNDS I HAVE RECEIVED. (Please contact the Financial Aid office if you have any questions.)
Approved
Denied
Approved
Denied
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