Repeat Option Request Form Tennessee Education Lottery Scholarship (Tels)

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Repeat Option Request Form
To submit the completed form: In person: MT One Stop Student
Services and Admissions Center (SSAC) – Room 210;
Tennessee Education
Mail: MTSU, MT One Stop, SSAC Room 260, 1301 East Main
Street, Murfreesboro, TN 37132; Fax: (615) 494-7770.
Lottery Scholarship (TELS)
LOTREP
Please note: You are required to meet with a counselor in the MT One Stop before submitting this form.
Name: ______________________________________
MTSU ID # : M ___ ___ ___ ___ ___ ___ ___ ___
Email Address: ____________________@mtmail.mtsu.edu Phone: (_______)_____________________
Please Note: If we need to contact you about your scholarship request or other matters, we will generally do so via your MTSU
email address. Please be sure to check your MTSU email account on a regular basis throughout the year!
Please provide the following information about the repeated course:
Class to be Excluded
Class to be Included
Term (e.g., Fall 2013)
Course # (e.g., ENGL2010)
Must be the same
course # as the
Course Name (e.g., Anatomy)
course to be excluded
Grade Earned (Must be a grade of A, B,
C, D, or F; cannot be a grade of W, I, or N)
School where you took the class (e.g.,
MTSU or Columbia State)
Please initial to indicate your understanding of the following statements:
_____ I am exercising my one-time-only Repeat Option to exclude the lower of two grades for the same course. I have
not exercised this option at MTSU or another school. I understand that all repeated courses, other than the
course listed above, will count in my TELS GPA.
_____I understand that exercising this option will affect only my TELS GPA and will have no impact on my MTSU GPA.
_____I understand that all courses, including both courses listed above, will count in my TELS attempted hours.
_____I understand that exercising this Repeat Option does NOT guarantee that my TELS GPA will meet the minimum
renewal requirements.
_____I have consulted with a counselor in the MT One Stop regarding this Repeat Option.
Required: MT One Stop Counselor Signature: ______________________________ Date: ________________
_____I understand that I will not be able to make changes to or withdraw my request after I submit it.
Student Signature: ___________________________________________ Date: _______________
 Processed  Not Processed: __________________________ E-mail
For Records/Schol Office Use Only
MTSU Course (Transfer #)
Term
New TLS GPA
New Status
X
Bracket
Initials
R
AHrs
Date
Initials _________ Date __________
Initials _________ Date __________
Updated: SZACRSE
SZATELS RHACOMM RPAAWRD Egrands ROANYUD
Revised WDM 4-14

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