COLUMBUS STATE COMMUNITY COLLEGE
PETITION FOR ACADEMIC REVIEW
MUST BE COMPLETED 60 DAYS PRIOR TO THE START OF THE SEMESTER FOR WHICH YOU SEEK READMISSION
PLEASE PRINT LEGIBLY AND COMPLETE THE GRAY SECTION PRIOR TO MEETING WITH YOUR ADVISOR
CougarID: ___________________________________
Name: (Last) _______________________________________ (First) _____________________________
Address: _____________________________________________________________________________
City: ______________________________________ State: ________________ Zip: ________________
Telephone Number(s): (Home) ________________ (Cell) ________________ (Work) _______________
Please explain what led to this dismissal. Attach any supporting documentation to the petition.
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Identify and describe three to five ways you will modify your behavior to assist in your academic success.
Continue on a separate sheet, if needed.
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ADVISOR TO COMPLETE
Semester of Review: ________________________ Program of Study: ___________________________
Total GPA Credits: ________________________ Cumulative GPA: ___________________________
COURSE RECOMMENDATIONS:
Semester/Year: ______________
Semester/Year: ______________
Course
Credits
Course
Credits
In signing below, I understand that the Academic Review Board will review my petition and determine whether another
readmission is warranted. The decision of the Academic Review Board will be final.
Student Signature Date Advisor Signature Date
RVIEW 03/12 OFFICE COPYWHITE / STUDENT COPYYELLOW
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