Academic Suspension Appeal July 2018
DICKINSON STATE UNIVERSITY
ACADEMIC SUSPENSION APPEAL FORM
in Part 2
PART I. DATE: ________________________________
Student’s Name: Mailing Address:
Home Phone Number: Student’s ID #:
Student’s Advisor:
I wish to appeal the Academic Suspension placed on my record at the end of the _________ semester.
REASON FOR SUSPENSION: (Check one) Low GPA:
Received all F grades:
I wish to appeal for the following reasons:
SIGNATURE OF STUDENT:
PART II.
1. ___________________ I recommend ________ ___________
of this request.
SIGNATURE, ADVISOR APPROVAL DISAPPROVAL
2. __________________ I recommend ________ ___________
of this request.
SIGNATURE, DEPARTMENT CHAIR APPROVAL DISAPPROVAL
3. ___________________ I recommend ________ ___________
of this request.
SIGNATURE, COLLEGE DEAN APPROVAL DISAPPROVAL
PART III.
Provost/ VPAA DATE
APPEAL APPROVAL CONDITIONS:
_____ Stude
nt must schedule and
attend weekly
academic/tutoring support sessions through the DSU
Academic Success Center (ASC). Failure to do so can
result in immediate suspension. ASC to send monthly
summary reports to the student’s advisor.
______Other:________________________________
___________________________________________
___________________________________________
Copies: Student, Registrar, Financial Aid, SSS, Student Affairs, Academic Success Center, Advisor
DIRECTIONS: Student completes PART 1 and gets the signatures of Advisor and Department Chair in PART 2.
Attach an unofficial transcript to this form and bring it to Academic Affairs in 119 May Hall.
