Fillable Form for your approved courses; you will not (University of Texas at Tyler)

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Form for your approved courses; you will not (University of Texas at Tyler)

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The Form for your approved courses; you will not (University of Texas at Tyler) form is 2 pages long and contains:

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  • 11 check-boxes
  • 25 other fields

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File type: PDF

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NOTE: Once completed, this form is valid for a single semester only. Revised: 06/2017
SOCIAL SECURITY NUMBER GENERAL MANDATORY DISCLOSURE
Disclosure of your Social Security Number (SSN) is required of you in order for The University of Texas at Tyler to complete your request, as mandated by State law (Texas Education Code Ch. 61). Further disclosure of your SSN is governed by the
Public Information Act (Chapter 552 of the Texas Government Code) and other applicable laws.
Notice about Information Laws and Practices
With few exceptions, you are entitled on your request to be informed about the information The University of Texas at Tyler collects about you. Under Sections 552.021 and 552.023 of the Texas Government Code, you are entitled
to receive and review the information. Under Section 559.004 of the Texas Government Code, you are entitled to have The University of Texas at Tyler correct information about you that is held by us and that is incorrect, in
accordance with the procedures set forth in The University of Texas System Business Procedures Memorandum 32. The information that The University of Texas at Tyler collects will be retained and maintained as required by
Texas records retention laws (Section 441.180 et seq. of the Texas Government Code) and rules. Different types of information are kept for different periods of time.
The University of Texas at Tyler
Undergraduate Student
Suspension Petition for Readmission
STEPS TO BE COMPLETED BY STUDENT:
1. Complete section A and attach a copy of your U.T. Tyler transcript to this form.
2. Schedule a meeting with your academic advisor to complete Section B and complete a Registration
Form for your approved courses; you will not have access to self-service enrollments while on
Academic Suspension.
3. Schedule a meeting with your academic dean to discuss and complete Section C.
4. Return completed petition and your Registration Form to the One-Stop Service Center (STE 230).
Name: _________________________________________ Student ID Number: _______________________
Major: ___________________________ Semester: Fall Spring Summer Year: 20_____
Primary Phone Number: _____________________ Alternate Phone Number: _____________________
Section A: Please summarize how you arrived at this point in your education. Please list how you plan to
change your academic status.
Student’s Signature: ______________________________________________ Date: ____________
International Counselor: ___________________________________________ Date: ____________
(Required for all International students)
Section B
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NOTE: Once completed, this form is valid for a single semester only. Revised: 06/2017
Academic Advisor: ____________________________________ Appointment Date: ______________
Review and Recommendations: (May include a review of deficiencies in: core, field of study, major,
minor, or sub-plan requirements. Recommendations may include support services, supplemental
instruction, counseling, advisor meetings, and/or enrollment restrictions. )
Readmit without restrictions Readmit with restrictions Do not readmit
For The Following Semester/Year (One semester only): ____________________________________
Academic Advisor’s Signature: ____________________________________ Date: ______________
or Department Chair’s Signature: ___________________________________ Date: ______________
Section C
Academic Dean: ______________________________________ Appointment Date: ______________
Recommendations:
Readmit without restrictions Readmit with restrictions Do not readmit
Dean’s Signature: _______________________________________________ Date: _______________
Return completed petition and Registration Form to One-Stop Service Center (STE 230).
OFFICE USE ONLY
Holds: No holds Hold(s) still pending as-of date: ____________ (Return form to student)
Completed by: _________________________________ Date: ___________________
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Form for your approved courses; you will not (University of Texas at Tyler)

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Completed 30 August 2020

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