For official policies regarding all excuse requests please consult the course syllabus and/or webpage.

Please neatly and legibly fill out all of the following fields:

Your Full Name: _______________________________     Login ID (ex. cs101001): _____________

Course (ex. CMSC 101): _____________________     Section (ex. 0101): _____________________

Date(s) for which you are requesting to be excused: ______________________________________
Assignment(s) for which you are requesting to be excused/receive an extension on:
__________________________________________________________________________________

Briefly explain in your own words the reason you are requesting an excused absence: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________

Sign here: ________________________________________________________

Attach to this form (either with a staple or paper clip) an original document (or a copy thereof) which appears on official paper (meaning it must have some sort of "letterhead" on it identifying the organization that is verifying your absence) that explicitly states your full name, the date(s) for which you should be excused, contact information that can be used to verify the documents validity, and some sort of description of the reason for the excused absence.

Name and Title of the contact person or organization found on the documentation:
__________________________________________________________________________________

Two or more of the following four fields must be filled out - note these fields are for the contact person or organization found on the documentation provided.
Phone Number: ____________________________     Fax Number: ___________________________
Address: ________________________________     Email: __________________________________
Address: ________________________________

For official policies regarding all excuse requests please consult the course syllabus and/or webpage.
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The following portion is to be filled in by the instructional staff:

Date processed: ___________________________     Initials of processor: _____________________
Brief summary of result:
__________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________