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Northern Illinois University

*Student Name
*Social Security Number
*Email Address
*Verify Email Address
*Program

*Status
*Course to be repeated
*Previously taken	semester of Year (YYYY)
Course Grade
	Have you ever requested and received permission to use the special repeat option? * Yes No
	If yes, what courses did you repeat? When? semester of Year (YYYY)
By entering my name below, I understand that the special repeat option is available for courses in which a grade below “B” was attained. If granted permission to repeat the course specified above, only the second of the two grades earned for the course will be computed in my grade point average.
Student Name Date (MM/DD/YYYY)
Department Decision Approved Not Approved
Chair/Grad Director Date (MM/DD/YYYY)


NOTE: *indicates required field