Grade Change Form

Student Last Name *

First Name *

Course Number *

Course Name *

School *

Session Course Taken (e.g. Fall 2004) *

Change grade from *

Change grade to *

Reason for grade change (REQUIRED) *

Course Coordinator Signature *

By checking this box, I am representing that I am the person named above and that I intend for my name to be treated as my electronic signature as if I had signed a paper version of the same.

Date *

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