Revised 6/16/09
PETITION
Return to: Vice President, Student Services
One College Drive
Blythe, CA 92225
Phone: 760. 921.5500
Name: Student ID #:
Address:
Home Phone: ( ) Cell Phone :( )
Email address:
Major: Counselor
Petition for:
a) Return to active status - Semester dismissed ____________ Year_________
b) For high school enrollment if below junior status.
(Attach enrollment forms. Board approval required.)
c) Academic Renewal without Course Repetition
d) Grade Appeal – Course Dep. & Number________ Semester _________ Year________
(Attach copies of assignments, please DO NOT submit originals.)
e) Other:
Clearly state your reason(s) for this request. Please print carefully, using back of page if needed. It shall be
your responsibility to provide any supporting documentation (i.e., transcripts and recommendations).
Student Signature: Date:
--------------------------------------------------------FOR OFFICE USE ONLY------------------------------------------------
Action:
Committee Signatures: Date
Vice President, Student Services: Date
Faculty (from program of study when applicable):
Final Action: Approve ________ Deny ________
