BYU Independent Study
Petition
Use Black or Blue Ink
Only
BYU Independent Study
110 MORC Provo UT 84602
STEP 1: STUDENT
INFORMATION
Full Name (Last, First, Middle)
BYU Net ID
Phone
Mailing Address
City
State
Zip Code
Are you:
A University Student? A BYU Student?
In the High School Transcript Program?
A High School Student? A BGS Student?
STEP 2:
C
OURSE
I
NFORMATION
COURSE NAME
Enroll Date
Confirmation #
COURSE NAME
Confirmation #
COURSE NAME
COURSE NAME
Confirmation #
STEP 3: R
EQUEST
Exam Retake
Resubmit Withdraw Refund Deadlines Other
Reason for Request: Medical/Clinical Academic Requirement Personal/Family Other
STEP 4: STUDENT
ST
A
TEMENT
Please write/type a detailed statement explaining the reason you are requesting an exception to BYU Independent Study policy.
STEP 5: SUPPORTING
D
OCUMENTATION
Attach all documentation from physicians, employers, counselors, etc. in support of your request. Your petition will only be reviewed after all supporting
documentation has been received by the Petitions Committee.
STEP 6: SIGN & SUBMIT
I hereby permit the supporting individuals to provide BYU Independent Study with information pertaining to my request and understand that
notification of the Committee's decision will only be sent by mail.
Signatur
e
Submit this form to:
BYU Independent Study • 110 MORC • Provo, UT 84602 • Fax: (801) 422-0102
OFFICE USE
ONL
Y
Approved
Denied
Pending
Comments:
Reviewed
Copy Placed on File
Submitted
Processed
Letter Sent
Note/Update to Student Acct.
Confirmation #
Enroll Date
Expiration Date
Expiration Date
Enroll Date
Enroll Date
Expiration Date
Expiration Date
STEP 1: STUDENT INFORMATION
STEP 4: STUDENT STATEMENT
Email Address
Office Use Only
