The burden is on the student to demonstrate that a final course grade was assigned in an arbitrary, prejudicial, or erroneous manner. Please attach any evidence, including documents or statements, you believe supports your request for a grade change. Please provide any additional information not requested in this form that you believe is relevant to your appeal.

Received by Office of Academic Affairs

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Signature _____ Date: _____

For Office Use Only □ Approved □ Denied

Date: ___