POST-CENSUS RE-ENROLLMENT FORM
RETURN FORM TO THE ONE-STOP SERVICE CENTER (STE 230)
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.
Questions regarding data collected may be directed to the Registrar. (HB 1922)
Rev. 06.2017
Printed Name: _______________________________________________________________ Student ID Number: ________________________
Semester/Year: ________________ Major: ______________________________________________ Phone Number: _____________________
Student Acknowledgements:
I understand and acknowledge that:
This form is to be used only to re-enroll in the exact courses and sections I was dropped from due to non-payment.
I am not permitted to add any new courses I was not already enrolled in prior to the Census Date.
I am responsible for paying all applicable late fees, up to and including the $250 Post-Census fee, after I have been re-enrolled.
Student Signature: ____________________________________________________________________________ Date: ________________
Class No.
Prefix & No.
No.
(College Algebra)
Number
SIGNATURE(S)
DEAN’S SIGNATURE REQUIRED: ________________________________________________________ Date: ______________
PROCESSED BY: _____________ ENROLLMENT DATE: ____________ ADD/UPDATE A PERSON SCREENSHOT ATTACHED: □ RESIDENCY DATA SCREENSHOT ATTACHED: □
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