2/18 OGS
Graduate students admitted to a graduate certificate or degree program who do not enroll for four consecutive terms,
including students returning from approved Leave of Absence, must submit a Graduate Re-enrollment Request to their
department. You may only re-enroll for the program to which you were previously admitted; you cannot change your
major with this form. If this request is supported by the department, the form is signed and forwarded to the Office of
Graduate Studies for processing. The completed Graduate Re-enrollment Request should be submitted to OGS at least
three weeks before the beginning of the term of re-enrollment.
When do you wish to resume study? Term __________________ Year __________________
Name __________________________________________________________ PSU ID# __________________________
E-mail (PRINT CLEARLY) _________________________________________ Day phone ________________________
Indicate your current status ___ U.S. Citizen ___ Resident Alien ___ Nonresident Alien
Degree (MA, MS, PhD, etc.) ___________________ Major _______________________________________________
Date of last attendance Term ____________ Year ____________
If you have attended any other colleges or universities since leaving PSU, list them here.
Location (City & State)
Dates Attended
Degree Received
From____/____ To____/____
From____/____ To____/____
From____/____ To____/____
Official transcripts from all colleges or universities attended since leaving PSU
must be submitted to the Office of Graduate Admissions.
I certify that all statements on this form are complete and true. Furnishing false or incomplete information is subject to
disciplinary procedures through the Dean of Student Life Office.
Student signature ______________________________________________________ Date _______________________
All graduate students must have the approval of their graduate program for re-enrollment.
Department approval ___________________________________________________ Date _______________________
Department Chair or Graduate Committee Chair
original signatures only; no stamps
Submit completed form, with department approval, to the Office of Graduate Studies
184 Parkmill, 1633 SW Park Avenue
Processed by Graduate Studies ________________________________________________ Date ___________________