Re-admission Applicant:
After completing the top portion, please submit the form to your most recent institution for completion.
Student’s Last Name – please print First Name, MI UST ID (optional)
Street Address/P.O. Box City, State, Zip
Phone Number Student’s Signature Date
Have you ever been subject to disciplinary action by any institution of higher education? Yes No
If yes, please provide further details below, including the nature of the disciplinary action and the name of the institution where the disciplinary action occurred.
Have you ever been judged delinquent by a juvenile court or convicted of a misdemeanor or felony-level jurisdiction? Yes No
If so, please provide further details below, including the date, court, and nature of the charge or conviction.
Please check all that apply: I am over the age of 25 I have not taken any college courses in the last 4 years
If you have checked both boxes above, you do not need to complete the rest of this form.
“I have applied to the University of St. Thomas for the academic term beginning _____________________________, and I authorize
__________________________________________________ to release the following information.” _______________________________________
Name of college/university Student Signature
Institutional Section
The student named above has applied for re-admission to the University of St. Thomas. This form must be on file before the student will be
considered for re-admission. Please complete the following questions:
Dates of attendance: _________________________________________
Is this applicant eligible to return to your institution? Yes No
Has the applicant been subject to either disciplinary action or probation while attending your institution? Yes No
If yes, please explain:
Do you know of any other behavioral issues or concerns regarding this student’s attendance at your institution? Yes No
If yes, please explain:
Additional comments that may be helpful:
_______________________________________________ ______________________________________________________
Signature of the Dean Date
_______________________________________________ ______________________________________________________
Print Name Daytime Telephone Number
_______________________________________________ ______________________________________________________
Name of Institution Institution Address
Please return this form as soon as possible to:
University of St. Thomas
Academic Counseling Office
2115 Summit Avenue, Mail OEC 119
St. Paul, MN 55105
(651) 962-6300 FAX (651) 962-5965
University of St. Thomas
Dean of Students Form
