Petition For Incomplete Grade Form
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1Revised: December 7, 2015
PETITION FOR INCOMPLETE GRADE
This grading option is reserved for classes in which the student has successfully completed 80% of the course with a passing
grade, but is unable to complete the remainder of the work on time due to an emergency or un‐foreseen circumstances.
**Forms will not be processed unless all information is completed and signatures are obtained.
**Note: Failure to remove the Incomplete Grade by the date specified in this contract will result in a “F” grade for the course.
STUDENT INFORMATION:
COURSE INFORMATION:
Name: ___________________________________
Term and Year: ___________________________________
Student ID: _______________________________
Course ID and Section: _____________________________
Advisor: __________________________________
Title: ___________________________________________
Instructor: _______________________________________
PETITION INFORMATION
Reason for Request: __________________________________________________________________________________
___________________________________________________________________________________________________
Date of Petition: _____________________
Incomplete in: Final Exam Other Assignments
Completion Contract:
Coursework to be completed by: _____________________
(Date must not be later than the beginning of final exams for the next semester.)
Final Exam before: _____________________ (Date must not be later than three weeks into the next semester.)
REQUIRED SIGNATURES
Student’s Signature: ____________________________________________________
Date: __________________
Instructor’s Signature: ___________________________________________________
Date: __________________
To be filled out by instructor:
Is the student’s grade at this point a passing grade? Yes No
What percentage of the course has student completed? ____________________
Registrar’s Office:
Student
has
has not accumulated more than two incompletes. (A registration hold is placed on students with two or more.)
Registrar’s Signature: ____________________________________________________ Date: __________________
Incomplete Recorded: _______________ Date: _______________ Grade Recorded: _______________ Date: _____________
Student Resource Center, 3500 Mountain Blvd., Oakland CA 94619 • Phone: 510.436.1133 • Fax: 510.436.1199 • Email: registrar@hnu.edu
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