Form C4

University of the East

RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER
College of Nursing

APPLICATION FOR REMOVAL OF X/INC/NYA GRADE

` ____/____/____
Date: ( mm / dd / yy )

The Dean, College of Nursing:

Dear Sir/ Madam :

_______ I would like to request your approval to take a SPECIAL EXAMINATION in:
_______ I would like to apply for removal of my X / INC / NYA / GRADE in:
_______ I would like to request for a CHANGE OF GRADE in:

SUBJ. CODE / SECTION : ____________________________ COURSE : ________________

SEMESTER/SY : ____________________________ CURRICULUM YEAR : ________________
FACULTY MEMBER : ____________________________

________________________________________
Student’s Name and Signature

____________________
Student Number

CERT IFICATION

This is to certify that ______________________________________, S.N. ___________________ was my student in the

subject and section indicated above and he/she was given a grade of X/NYA/INC because of the following reasons _____________
__________________________________________.

MIDTERM: __________ ____________________________________________________

(figure) (word)

________ She/he was given a special examination.

________ She/he complied with all the requirements of the subject.
________ She/he was given an incorrect final grade.

In view of this, his/her FINAL GRADE is as follows:

__________ ___________________________________________________
(figure) (word)

_________________________________________
Signature of Faculty over Printed Name

ACTION OF THE DEAN

____/____/____
Date: ( mm / dd / yy )

______ : APPROVED
______ : DISAPPROVED

_________________________________
College Dean

IMPORTANT: STUDENTS ARE NOT ALLOWED TO HAND-CARRY DULY ACCOMPLISHED FORMS BUT SHOULD BE SUBMITTED
PERSONALLY BY THE FACULTY MEMBER CONCERNED TO THE OFFICE OF THE DEAN. THE MIS OFFICE WILL PICK FROM THE
RESPECTIVE DEAN’S OFFICE THE ORIGINAL COPY OF THIS FORM FOR DATA ENCODING.
Revised 7/2010