MJC Enrollment Services Phone (209)575-6853
EAST 435 College Avenue, Student Services Bldg. 1st Floor WEST 2201 Blue Gum Ave, Yosemite Hall 1st Floor
To be completed by the STUDENT:
03/2020_SJB
Request for Reinstatement
Submit this form ONLY if the student was accidently dropped AFTER census
AND had been enrolled in the course PRIOR to census. Submit completed form
by email to MJCESeForms@mjc.edu.
Explanation for requesting reinstatement:
A reinstatement can only be submitted if you were enrolled in the course prior to census and you were dropped in error after the
census date. Please explain how the drop occurred:
Instructor dropped student accidently Student dropped self accidently Other ( please explain):
I understand that by signing this form all information listed is true and subject to approval. If approved, I agree to pay all enrollment fees associated
with this course. If denied, I understand I will be notied by my MJC student email and agree to stop attending this class.
Student Signature: Date:
OFFICE USE ONLY
Approved Denied Census Date:
Dropped Date & by who: STAC RGCS ReBill
Sta Initials: Date of Reinstatement: Notied Student
Today’s Date:
Student Information
First Name: Middle Initial: Last Name:
Student ID: w Birthdate: Phone Number:
Course Information:
Course Name: Section #: Course Start Date:
Semester/Year: Summer Fall Spring
To be completed by the INSTRUCTOR:
*If the instructor dropped the student, it is the instructors responsibility to notify the student via their student email.
Approved Denied Student’s First Date of Attendance:
Student has been notied through their student email Date of notication:
Instructor Signature: Date:
Dean Signature: Date:
*If there is no student signature, the Division Dean signature is required.
click to sign
signature
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click to sign
signature
click to edit
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click to sign
signature
click to edit
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