Admissions and Records Office
Dismissal Petition
Academic/Progress - Reinstatement
Semester of Dismissal: Fall Spring Year: Academic Dismissal Progress Dismissal
Academic & Progress Dismissal
Check One:
. .
Required Steps and Documentation (Incomplete petitions will not be accepted):
Step 1 - Use the reverse side of this form to:
A. State the reason(s) for substandard grades and/or frequent withdrawals.
B. Explain what measures you will take to improve your academic performance.
Step 2 - Attach documents to verify and support your reasons for poor academic performance.
2A - REINSTATEMENT ONLY- Schedule a counseling appointment in E1-127 to obtain a
Student Educational Plan (SEP).
Step 3 - Submit all documents to the Office of Admissions.
Your petition will be reviewed and you will be notified by the Admissions Office of the decision within 15 calendar days
after the committee decision.
Student Signature Date
Approved Denied
Committee Members:
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
VP Appeal: Approved Denied
Signature: Date:
Office Use Only
Name: Student ID #:
Last First
Address: Date of Birth:
Number Street
City State Zip Contact Number:
Reinstate I have not enrolled at ELAC
in the past two major semesters
(Fall/Spring) and request permission to re-
One Year DismissalI was dismissed
and request to continue enrollment at
Admissions Date Stamp
& Staff Initials
ELAC_Appeal_Dismissal_Petition_pg.1 rev. 02/11//2015
Please state the reason(s) and attach proof for substandard grades (D, F, NCR) and/or frequent
withdrawals or incompletes (W, INC):
First Semester on Probation: Semester Year
Second Semester on Probation: Semester Year
Third Semester on Probation: Semester Year
Please explain what measures you have taken or will take to improve your academic performance: