Name: WID:
Adviser: Class:

Subject of Petition:

STATE FULLY THE NATURE OF THE PETITION AND REASONS FOR IT:

Student Signature (Required): ______________________________
Date: ___________

ADVISERS PLEASE NOTE:

^{Every petition must bear the signature of the student's adviser indicating that the petition is submitted with the adviser's knowledge. Complete statements from advisers concerning the merits of a petition will be appreciated. These may be made on the reverse side of the original copy of this form or in a separate memorandum. In any case, advisers are requested to check one of the following.}

Petition recommended for approval        Petition recommended for disapproval
No recommendation concerning petition

Adviser's Signature: ____________________________ Date: ___________

BOARD OF REVIEW ACTION (Do not write in this space)

Date: ______    Action:

Remarks:

Board of Review Chair Signature: __________________________

ATTACH COMPLETE SEMESTER CLASS SCHEDULE  (Only if Appropriate to Petition)