Johnston Community College – AOM Revised 6/11
StudentReinstatementForm
To be completed by student:
Student’s Name:____________________________________________Date Requested___________________
Valid Email Address:________________________________________Student ID#._____________________
Course Prefix and Section #___________________________________________________________________
Instructor:_________________________________________________Semester/year____________________
To be completed by instructor:
I give approval for_____________________________________to be reinstated into the above course.
Student Name
Student agrees to complete the following assignments and requirements:
REINSTATEMENT REQUIREMENTS:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Instructor Signature:_______________________________________________________ Date:_____________
Student Signature:_________________________________________________________ Date:_____________
Dean Signature____________________________________________________________Date:_____________
**Reinstatement confirmation will be sent to your above listed email**
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I am denying reinstatement for ________________________________________________________________
Student Name
Reason(s) for denial:
_________________________________________________________________________________________
_________________________________________________________________________________________
Instructor Signature:_______________________________________________________ Date:_____________
Dean Signature:___________________________________________________________Date:_____________
