Office of Admissions & Records
3000 Campus Hill Drive
,
Livermore, CA 94551
(925) 424-1500
•
Fax (925) 606-6437
Email: lpc-admissions@laspositascollege.edu
REQUEST FOR REVIEW
SEMESTER
:
SPRING SUMMER FALL YEAR: 20
STUDENT ID NUMBER:
N
AME:
STREET:
APT/UNIT #:
CITY:
STATE:
ZIP CODE:
PHONE:
( ) -
EMAIL:
Please state the purpose of your request and provide any information that will be helpful to the “Appeals Committee”.
Attached pertinent documents (medical records, etc.) Request will be reviewed and notification of the final decision
within 3 weeks.
By signing below, I certify that my request form is complete and accurate.
ST
UDENT SIGNATURE DATE
S
ubmit this form to: (Attention: Extenuating Circumstances Review Form)
Mail to: Las Positas College, Office of Admissions & Records, 3000 Campus Hill Drive, Livermore, CA 94551
Fax to: (925) 606-6437
Email to: lpc-admissions@laspositascollege.edu
ADMISSIONS OFFICE USE ONLY
APPROVED DENIED APPROVED BY: DATE:
DA
TE STUDENT NOTIFIED: PROCESSED BY: DATE:
EXTENUATING CIRCUMSTANCES
