Special Letter

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LOCAL GOVERNMENT TRAINING INSTITUTE

APPLICATION FOR SPECIAL EXAMINATION

This is made under rule (ix) of the Institute’s Examination Regulations.

This form must be filled by student (s) wishing to defer Examination (s) and submitted to the
head of Department.

1. Student particulars
Names……………………………………..………. Reg. No……………………..……….
Programme………………………………………… Year of Study……………………….
2. (a) Module (s) to be deferred (indicate the codes and names of modules)
Modules (s) code Name of Module
……………………… ………………………………………
……………………… ………………………………………
……………………… ………………………………………
……………………… ………………………………………
……………………… ………………………………………
……………………… ………………………………………
……………………… ………………………………………
……………………… ………………………………………
……………………… ………………………………………
(b) Reason for deferring examination (tick whichever applicable)
Medical grounds ( ) Social problem ( ) Sponsorship Problem ( )
(c) A brief statement of particulars of the reasons (s) indicated above
………………………………………………………………………………………………
………………………………………………………………………………………………
3. Expected year / semester of sitting for deferred examination (s)…………………………..
4. Amount paid for deferring examination Tshs………………………………….Receipt
number………………………………………..(attach the original receipt).
5. This form has been submitted today…….…..(Day)…………...(Month)………….(Year)
Signed…………………………………………..
For official use
1. Recommendation of the Head of Department

………………………………………………………………………………………………………
………………………………………………………………………………………………………

Name: Signature

2. Recommendation of the Dean of Students

………………………………………………………………………………………………………
………………………………………………………………………………………………………

Name: Signature

3. Decision of the DR-ARC

Approved Not Approved


Name: Signature:
Coursework
Name of Student:
Course:
Course Course Name Assign Test Assign Test Total Lecturer’s
Code 1 1 2 2 signature

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