Southern Polytechnic State University
Petition to the Faculty
Name: ________________________________________________________________________
Street Address: _________________________________________________________________
City: _____________________________ State: ______________ Zip Code: ________________
Home Phone: _________________ Work Phone: _________________ Email: ________________
SSN: ______________________ Date: __________________ Major: _____________________
Can we contact you at work? ___Yes ___No
I am respectfully petitionint the Faculty of SPSU for permission:
___ Overload Credit Hours
___ Extend "I" Grade *
___ Receive Ten-Year Credit **
___ Receive Graduation Residency Waiver
___ Receive 25% Requirement Waiver
___ Retain Previous Catalog for Graduation
___ Withdraw Completely From School After Deadline *
___ Withdraw Partially From School After Deadline *
___ Exclude Previous Major Courses From Graduation Totals
___ Other: ______________________________________________
* Requires signature of both the instructor and the instructor's department head.
** Requires course department head's signature, if the course is taught outside your major department. If request is for transfer credit, you must attach a copy of your transfer evaluation.
for the following reason(s): _________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
If necessary, attach additional page(s) and / or supporting documents.
I understand that I must obtain the signature of my major department head prior to submitting this petition to the Registrar's Office. Furthermore, I realize when applicable, I need to obtain the signatures of my instructor(s) and the instructor's department head(s) before I obtain the signature of my department head.
Finally, I will not assume this petition will be approved because of an instructor's or department head's recommendation in my favor. I realize any action on my request is not complete until the committee's recommendations are acted on by the general faculty.
Petitioner's Signature: __________________________________________________________
__ Recommended or __ Not Recommended
Comments: ______________________________________________________________________
_________________________________________________________________________________
Course Instructor's Signature: ________________________________________________
__ Recommended or __ Not Recommended
Comments: ______________________________________________________________________
_________________________________________________________________________________
Course Department Head's Signature: ________________________________________________
__ Recommended or __ Not Recommended
Comments: ______________________________________________________________________
_________________________________________________________________________________
Major Department Head's Signature: ________________________________________________
For Office Use Only
__ Recommended or __ Not Recommended
Acted on by: __ Committee or __ Registrar's Office or __ Academic Affairs
Comments: _____________________________________________________________________
_________________________________________________________________________________
Registrar's Representative: _________________________________________ Date: ____________