CSC 165H --- Fall 2014: REQUEST FOR SPECIAL CONSIDERATION
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  Student number: ___________________     Lecture section: ___________________


  Last name:      ___________________     Instructor:      ___________________


  First name:     ___________________     Name of TA:      ___________________


  Email address:   __________________     Tutorial room:   ___________________


  Assignment/Test number: ___________     Date of request: ___________________


Reasons for request (be concise and clear, use the reverse if needed; submit
supporting documentation together with this form, directly to your instructor):