"G" GRADE REQUEST FORM

 I wish to receive a "G" in (course and number)                                                                              

 I understand that all course requirements must be completed within one year of my signature date.

 I intend to complete the course requirements (listed below) no later than (date)                               

 REQUIREMENTS 

 Name of student (please print)                                                                                       

 Student's signature                                                                        

 Date                                                

 Instructor's signature                                                                        

 Date                                                 

 Signature of Vice President for Academic Affairs                                                                          

 Date                                                  

 Additional comments                                                                                                               

 Completed form is submitted to the Vice President for Academic Affairs, 107 BSC or FAX to 814- 827-5505