Grade Change Request Form

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Policy No.IS100.18
GRADE CHANGE REQUEST
Student Name: _______________________________________________________________________
Social Security Number: _______________________________ Campus________________________
Program Major: ________________________________ Student Phone: ________________________
Address: ___________________________________ City/State/Zip: ____________________________
Course
Credit
Change
Semester
Year
Section
Grade
Number
Hours
Grade To
Removal of Incomplete (“I”)
Contract Completed
_____
___________________
Date
Correction of Grade (Attach copy of grade book and/or attendance record)
_____
Explanation Required – Reason for Requesting Change:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________
_______________
Instructor Signature
Date
APPROVED:
____________________________________________
_______________
Department Head Signature
Date
RECEIVED:
____________________________________________
_______________
Registrar
Date

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