No. Dok.

: FO-QP-PU-AAB-024/01
FORMULIR
Berlaku sejak : 1 Desember 2015
MAKE-UP EXAMINATION Revisi : 00
REQUEST FORM Halaman : 1 dari 4

MAKE-UP EXAMINATION REQUEST NO: ……………..……………/ Date : ………………..…………

Instructions to Student:
Students who are unable to conduct the exam at the prescribed time due to several reasons such as
scholastic events, medical condition, death of a family member or other unavoidable circumstances may
request make-up exams.

Please note the following conditions carefully:

1. Request for make-up exams must be submitted to Academic Administration Bureau no later than
THREE(3) working days after the date of the prescribed examination.
2. Attach supporting documents such as your Physician’s statement or a valid permission letter from
Vice Rector 3 if you are attending an event for the university.
3. The make-up Exams Request fee is Rp. 50.000,00 per course. Payment can be made in the Finance
Bureau after you have obtained your Lecturer’s and Head of Study Program’s approval.Student
who is unable to attend examinationdue to participation in specific scholastic event (by University’s
request) or acute medical condition may be exempted from paying Request Fee. Exemption is
subject to approval by the Head of Study Program.
4. Make-Up Exam is not a right and permission is only given in exceptional circumstances. Your
Lecturer and Head of Study Program has the right to deny your request if you fail to provide
sufficient evident on the circumstances that prevented you from sitting the examination on the
prescribed date
5. You are not allowed to defer a make-up exam. Failing to attend a make-up exam will automatically
grant you a ZERO(0) score on your exam

To be completed by Student

Student’s name :
……………………………………………………………………………………………
…

Student ID :
……………………………………………………………………………………………
…

Study Programme :
……………………………………………………………………………………………
…

Course name/code :
……………………………………………………………………………………………
…

Lecturer’s name :
……………………………………………………………………………………………
…
 No. Dok. : FO-QP-PU-AAB-024/01
FORMULIR
Berlaku sejak : 1 Desember 2015
MAKE-UP EXAMINATION Revisi : 00
REQUEST FORM Halaman : 2 dari 4

Date / Time of Original Exam :

……………………………………………………………………………………………
…

Reasons for Make-Up :

Request ……………………………………………………………………………………………
(Provide a letter from your …
Physician or other
supporting document) ………………………………………………………………………………………
………

………………………………………………………………………………………
………

I hereby declare that I have read and understood all the instructions stated above

Student’s signature :
……………………………………………………………………………………………
…

To be completed by Course Coordinator

Based on the provided supporting documents and on the class policy, I approve / reject
this request of Make-Up Examination.

Additional Notes :…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

Suggested Date/Time :…………………………………………………………………………………………

Approved/Rejected by,

……………………………………………
…
(
)
 No. Dok. : FO-QP-PU-AAB-024/01
FORMULIR
Berlaku sejak : 1 Desember 2015
MAKE-UP EXAMINATION Revisi : 00
REQUEST FORM Halaman : 3 dari 4

To be completed by Head of Study Programme

Based on the provided supporting documents and on the class policy, Iapprove / reject
this request of Make-Up Examination.

Exemption from Request Fee : Yes / No

Additional Notes :
…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

Approved/Rejected by,

……………………………………………
…
(
)

To be completed by Finance Department

Clearance checklist Clear from all financial obligations

Paid Make-Up Exam Request Fee

Additional Notes :
…………………………………………………………………………………………

Cleared by,

………………………………………………………………
( - Finance Department)
 No. Dok. : FO-QP-PU-AAB-024/01
FORMULIR
Berlaku sejak : 1 Desember 2015
MAKE-UP EXAMINATION Revisi : 00
REQUEST FORM Halaman : 4 dari 4

To be completed by Academic Administrative Bureau

Approval Checklist Approval from Course Coordinator

Approval from Head of Study Programme
Attached valid supporting documents
Attached clearance form from Finance
Attached receipt of Make-Up Examination fee from
Finance
Room is available on the suggested Date/Time.
Proctor is available on the suggested Date/Time.

Additional Notes :
…………………………………………………………………………………………

Processed by,

……………………………………………………………….
(Head of Academic Administrative Bureau)