This form must be word processed.  No hand written exceptions will be considered.

Please address the following items in order:

Name:

Date:

Purpose for Exception (summarize the requested exception):
 
 

How will the exception impact your course requirements?
 
 
 

How will you implement the requested exception?
 
 

Additional notes for consideration:
 

Students' Signature and Date:
 
 

Instructor's Signature and Date: