Pass

Name*
First Last
NOC ID:*
Course Department:*
Course Number:*
Course Section:*
Title of Course:*
My reason for changing my grade is?*
Student Electronic Signature:*
First Last
I certify by signing this document that I have explored all the ramifications of this grade change including but not limited to financial aid, licensure, transfer credits, Veteran’s benefits, admission to professional programs, etc. I further understand that once this grade change has occurred, I will not be able to request a reinstatement of the former grade.
Date*
MM slash DD slash YYYY

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