Fillable 2014 Undergraduate Academic Petition Form printable pdf download

Registrar’s Office

Undergraduate Academic Petition Form

For students in the Faculties of Education, Fine Arts, Health, Science or Lassonde School of Engineering only. Other

students should consult with their home Faculty regarding petitions.

Incomplete petition submissions will not be accepted for processing.

You must ensure all petition documents are submitted at the same time in one package. Incomplete petitions will be

cancelled and the documents will be returned to the local mailing address currently on your record within the Student

Information System. E-mail submissions will not be accepted.

Student Information (please print)

Student Number

Last Name/Family Name

Given Name(s)

Telephone

E-mail

Home Faculty

Keep your information up-to-date! Make sure we have your current contact information by visiting the My Student Records section

My Online

Services.



Are you graduating this year?

Yes If yes, select one:

June

October

_____________________________________________________________

Which Faculty regulation are you petitioning?

Documents to be submitted with petition

Included

Office Use

Applicable



Undergraduate Academic Petition Form (mandatory)



Petition Letter (mandatory)

Course Performance Summary (CPS) – one CPS form for each course being petitioned. List each course below.



Attending Physician’s Statement (original only)



Counselling & Development Counsellor Statement



Petition to Enrol Late Form (must be signed)



Financial Petition Form



Deferred Standing Agreement (if refused by instructor)

Additional Documentation (please specify)



I declare that the information on this form and all statements in the attached petition letter and supporting documentation are true, complete and accurate. I understand that

any misrepresentation of this information may lead to a charge of breach of academic honesty. I consent to the disclosure by York University of personal information including

the information I have given on this form and the associated supporting documentation to members of the petitions adjudicating committees and associated administrative

staff. I confirm that ALL the necessary supporting documentation for my petition is enclosed. I also understand that if any required documentation is missing, my petition will

be cancelled and returned by mail.

Student’s Signature

Date (dd/mm/yy)

Protection of Privacy: Personal information in connection with this form is collected under the authority of The York University Act, 1965. The information will be used to

process and adjudicate your petition or appeal, and for related record-keeping purposes. If you have any questions about the collection, use or disclosure of this information

by York University, please contact the Manager, Registrarial Services, W120 Bennett Centre for Student Services, York University, 4700 Keele Street, Toronto ON, M3J 1P3,

416-872-9675.

Office Use Only

Date Received:

______________________________

Initials:

___________________

Undergraduate Academic Petition Form, October 2014