Petition by a Student for a Course Grade of AW
PURPOSE: Students may use this form to petition to be assigned a grade of AW (administrative
withdrawal) for a course. Students initiating a withdrawal from all courses in a semester should
Withdraw from Term via WebOPUS.
This form will only be reviewed for students who:

have exceeded their lifetime limit of three student-initiated course withdrawals (CW) or
who have missed the deadline to be assigned a grade of CW
AND

have documentation of compelling and unforeseen obstacles to course completion (e.g.,
severe injury or illness, or death in family)
AND

cannot complete course requirements without retaking the course, thereby not
qualifying to be assigned a grade of I (incomplete).
INSTRUCTIONS FOR STUDENTS: Complete this form. If an instructor or advisor is able to attest
to the presence of unforeseen, compelling reasons why this course could not be completed,
please ask him or her to email such reasons to [email protected]. The completed
and signed form will be reviewed by the Provost’s designee. Petitions that are approved will
result in a grade of AW for the course.
DEADLINE: Submit form to [email protected], by 4:00 p.m. Wednesday of the last
week of classes.
Section I – Student’s Information
FLC ID #
Printed Name:
11/18/2013
Section II – Term and Course Information
Fall 20____
Spring 20____
Credits:
Credits:
Summer 20____
Circle summer term(s):
Credits:
CRN #:
Course:
Course Title:
1
2
3
4
5
Section III– Reason for Request
PRINT a detailed explanation relevant to request: 1) why was grade of CW not elected; 2) what is the
compelling and unforeseen obstacle to course completion (please attach documentation); 3) what
course requirements have you completed and which still remain to be completed. Attach additional
sheet if required.
By signing this form, I make known that I am aware of the fact that withdrawing from a course might
affect my eligibility for financial aid, health insurance, course registration, etc.
Student’s Signature:
Date signed:
Section IV – Decision by Provost’s Designee
Approved
Designee’s Signature:
11/18/2013
Not Approved
Date signed: