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Please
print and complete form.
I request
exemption from the Dining Plan normally required of on-campus
residents on the basis of one of the four special situations noted
below. I certify that the indicated situation is fully valid in
my case and that it has been approved by the authorized University
Official whose name appears below.
My Name: ____________________________________________________
SSN: _______________________________________________________
Cancel
Dining Plan Level: _________ • cancellation
fee 30.00
(PLAN LETTER)
•
or •
Reduce
to Plan Level: A • B • C • D • E
• F • J • G • H • I
• change fee 20.00
(CIRCLE
ONE)
Certification for the reason indicated below:
(CHECK ONE) 9
_____ Academic
Withdrawal / Leave of Absence • Office of University Registrar
_____ Moving
Off Campus • Office of Residential Life
_____ Medical
Need • Office of Student Health
_____ Religious
Conviction • Office of the Director of Religious Life
NOTE: If your request falls outside of these four circumstances,
you must appeal your exemption/cancellation directly to DUSDAC,
using the DUSDAC Appeal Form.
DATA BELOW FOR ADMINISTRATIVE USE ONLY
Reason for
Approval/Denial:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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