Academic Standards Committee Petition For Special Consideration Page 2
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2ACADEMIC STANDARDS COMMITTEE PETITION FOR SPECIAL CONSIDERATION
,
Name _________________
_________________________
Student ID Number ______________________
Last
First
MI
Address ________________________________________
Day Telephone Number ___________________
________________________________________
CSUS Graduation Date ___________________
City
State
Zip
Email Address(es) __________________________________________________________________________
I. Special Consideration Request (check appropriate box)
☐ Delete Course ___________________
Grade ______ from Semester and Year ___________________
☐ Add Course _____________________
Grade ______ to Semester and Year _____________________
☐ Extend Incomplete Deadline _________________ Semester and Year course taken ________________
☐ Other _______________________________________________________________________________
II. Reason for Request (attach verification and documentation)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Student’s Signature ___________________________________________ Date _______________________
III. Instructor and Department Chair Recommendations
☐ Approved
☐ Denied Instructor’s Signature ____________________________ Date ______________
List course to be added __________________ *Grade ______ Semester ____________________ Units _____
* Must be filled in by instructor of record.
Comments ________________________________________________________________________________
☐ Approved ☐ Denied
Department Chair’s Signature _____________________
Date ______________
Comments ________________________________________________________________________________
IV. Academic Standards Committee Action
☐ Granted
☐ Denied By ____________________________________ (Chair of ASC) Date___________
Action taken _______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Record posted by ___________ Date ____________
AU 4/2015
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