Fillable Grade Change Petition Form printable pdf download

Grade Change Petition

Clearly PRINT all required information in ink

(NOTE: Time limit for submittal of Grade Change Petition is one year from end of semester in which grade was earned)

Student Information

Name __________________________________________________________ Student ID ________________________

Last

First

Address ________________________________________________________ Date of Birth ______________________

Street

Apt

City

State

Zip

Telephone (___) ___________________ Telephone (___) ___________________ Email _________________________

Day

Evening

Course Information

Course & Number _______________________ Units _____ Semester ____________ Year ______ Section No. ______

Instructor ______________________________________ Grade Assigned __________ Grade Requested __________

Justification for Grade Change

The determination of the student’s grade by the instructor is final in the absence of mistake, fraud, bad faith, or

incompetency. The removal or change of an incorrect grade from a student’s record shall only be done upon authorization

by the instructor of the course. Grade Change Petitions must be submitted within one year after the grade was

assigned. In the case of fraud, bad faith, or incompetency, the final determination concerning removal or change of grade

will be made by the College President or designee.

Attach copies of any documents that prove there was a discrepancy between the instructor’s stated grading system (listed

on class syllabus) and the grade you received. If you are requesting a grade to be changed to a “W”, attach proof that you

attempted to drop your class before the college deadline. Remember that it is the student’s responsibility to drop a course

before the listed deadline.

_________________________________________________________________________________

Student Signature __________________________________________________________ Date ___________________

Do Not Write Below This Line – Official Use Only

Instructor:

□ Approval

□ Denial

Comments: ________________________________________________________________________________________

___________________________________________________________________________________________

Instructor Signature: _________________________________________________ Date: _________________________

This is to certify that the information on this petition is correct, that the instructor above is authorized to make this grade

correction, and that this is his/her signature.

Department Chair Signature: __________________________________________ Date: _________________________

Dean Signature: _____________________________________________________ Date: _________________________

Revised December 2011

Grade Change Petition Form