Petition for Reinstatement
Name
ID#
Last
First
MI
Address
Phone
Date of birth
City
State
Zip
Email
Program of Study
Semester Dismissed
Progress Dismissal Yes No
Academic Dismissal Yes No
Semester to be Reinstated
Describe what events took place impacting your academic performance. (Check all that apply.)
Health (birth, medical, injury, accident)
Gaps in college enrollment
Life changes (death of a loved one, divorce, financial concerns)
Other
Employment (loss of job, new job, change in work hours)
`
Based upon the boxes checked above, explain in greater detail what happened and your plans to improve your
academic performance. Attach any pertinent supporting documentation.
Student signature: Date:
RECOMMENDED SCHEDULE ~ AEP Counselor initials Date
Name of course
Section #
Units
FOR OFFICE USE ONLY:
Approved Approved contingent upon conditions listed below Denied Revise and resubmit
Comments:
Student Petitions Committee Signature: Date:
Instructions
Complete the form. (Do not leave any blank answers.)
Meet with a counselor to complete the Recommended Schedule section.
Attach supporting documentation that would be helpful in reviewing your case.
Submit completed form to the Admissions & Records Office.
Decisions will be made by the Student Petitio
ns Com
mittee
Educational Plan Complete
Yes - Attach a copy
No - Schedule a follow-up counseling appt. for Ed. Plan
A
ppointment Date/Time: _________________________
Note: After the follow-up appointment,
submit the Ed. Plan (CEP or as many terms as
possible) to the Admissions & Records Office.
click to sign
signature
click to edit
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome