Special Exemption Request Form

Name *

First

Middle

Last

Prior Name(s)

First

Middle

Last

JALC Student ID *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Telephone/Cell Number *

DOB (MM/DD/YYYY) *

Email Address *

Email

Confirm Email

Request

List courses and semester *

Please describe *

Justification *

You may attach up to three documents to support your justification. Please attach documents as either a Microsoft Word document or an Adobe PDF document. The maximum file size for each document is 10 MB.

Supporting Document(s)

Click or drag files to this area to upload. You can upload up to 3 files.

Verification *

By checking this box, you are signing this document electronically and you verify that the information provided is accurate and true.

This form takes 4-6 weeks to be reviewed. An email will be sent to the student’s Volmail account after a decision has been made.

JALC.EDU

Admissions and Records

Special Exemption Request Form