I hereby request that I be excused from taking the exit exam for the
(Spring ________, Summer _________, Fall __________) semester.
YR
YR
YR
***************************************************************
I HAVE PREVIOUSLY TAKEN THIS EXAM:
DATE (SEMESTER AND YEAR EXAM WAS TAKEN: ______________
INSTITUTION: ________________________________________________
Student Name: _________________________________ I.D.#______________
Phone #: _______________________ E-Mail address: ___________________
Street, City, Zip: _________________________________________________
Please note that it is the student’s responsibility to submit this form to the Assessment Office/Student Services as soon
as possible.
Signature: ______________________________ Date: ___________________
Office use only
Exam date:_______________
PPE scores: Composite __________ Essay __________
WORKKEYS scores: App Math_____________ Reading_____________ Loc Info______________
Approved/Disapproved ______________________________
Director of Assessment
Date: _______________
Student notified:
Date:
Updated: 6/12/12