Academic Petition Form
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1S U N Y I T • 1 0 0 S E Y M O U R R O A D • U T I C A , N E W Y O R K 1 3 5 0 2 • ( 3 1 5 ) 7 9 2 - 7 2 6 5
ACADEMIC PETITION FORM
Used to request waivers of college policy.
INSTRUCTIONS: Type or print with a ball point pen. All copies must be legible. Be specific and include all relevant information to support
your request. Attach additional sheets as needed. Please submit the completed petition to the your instructor or advisor who will forward the
form for appropriate approvals.
NAME ______________________________________________________________________
MAJOR ______________________________________________
ADDRESS ___________________________________________________________________
SUNY ID # ____________________________________________
CITY __________________________________________ STATE _______ ZIP ______________
PHONE _______________________________________________
E-MAIL ______________________________________________
SPECIFIC ACTION REQUESTED: ________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
JUSTIFICATION: _____________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
__________________________________________________________
Student’s Signature
Date
INSTRUCTOR, ACADEMIC ADVISOR – Comments or signature as needed.
■
■
Approved
Disapproved
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
Required Signatures
Additional signatures that may be required will be obtained by the Registrar’s Office
____________________________________
____________________________________
■
■
■
■
Signature of Academic Chair
Date
Approved
Disapproved
Provost
Date
Approved
Disapproved
____________________________________
____________________________________
■
■
■
■
Signature of Registrar
Date
Approved
Disapproved
Signature of President
Date
Approved
Disapproved
____________________________________
____________________________________
■
■
■
■
Additional Signature as Required
Date
Approved
Disapproved
Signature of Bursar/Financial Aid
Date
Approved
Disapproved
Comments _________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
Rev. 9/10
PROCESSED BY: ____________ DATE: ____________________
Distribution by Registrar’s Office ONLY:
WHITE - SFS Office; YELLOW - Registrar; PINK - Student
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