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Summary: STUDENT'S NAME AND ADDRESS STUDENT ID NUMBER
Last Name First Name Middle Name
Address
Y E A R Fall
City / Town Prov. Postal Code
Y E A R Winter
REQUESTED FOR: Y E A R Spring
Home Phone Business Phone
E-mail
REASON (check one) DOCUMENTATION REQUIRED
Illness or Accident A completed Student Medical Certificate form available from the FGSR web site
Compassionate Serious illness or death in immediate family (letter from physician / copy of death certificate or obituary)
* Other * Please explain:
Supporting documentation is: Attached To follow
Deferral is requested for the following course: [Primary (lecture) section only]
What was the last date of attendance for the course?
Student's Signature Date
Yes No
OR
SECTION 3: To be completed by FGSR
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