1. Student Name:
2. Social Security Number:
3. Level of Study:
4. Petition Based on Duty Assignment of:
5. Date Reported to a command in Georgia:
6. Duty Station of Active Duty Military Person:
7. Anticipated Date of Discharge or Transfer from Georgia:
8. Semester(s) for which waiver is requested: through
9. Address:
10. City:
11. State:
12. Zip:
13. Daytime Phone:
14. Evening Phone:
I hereby swear to the authenticity of the information provided and am aware of the student
responsibilities set forth in the regulations of Valdosta State University appearing on the
reverse side of this request. A copy of my military orders stationing me to the State of
Georgia and a legible copy of my current Military ID (front and back) is attached.
Date: ___________________
Military Sponsor Signature:___________________________________________________
Student Signature (Spouse or Dependent): _____________________________________
Submit to:
Valdosta State University
Office of the Registrar
1500 N. Patterson St.
Valdosta, GA 31698
Effective Term: __________________ Renewal Required Before: __________________
Waiver Approved By: ____________________________ Date: _______________________
|