Petition Request
Family Name
First Name
Middle Initial
Course
Year
Address for Reply
Telephone Number
E-mail address
MIT id number
Please explain circumstances in the space below.
Discuss this petition request with your Faculty Advisor, Registration Officer, or CGSP Representative who in turn should provide below the reasons for approving/not approving this petition.
Please print and sign name (Faculty Advisor/Registration Office/CGSP Representative)
Student's signature
Dean, Undergraduate Education
Dean, School of Hum. and Soc. Sci.
Dean, Grad Education
Instructor
Athletics Dept.
Petition to (please check one):
COC E19-335
CAP 7-104
CGSP 3-136
Registrar's Office E19-335
