Student Academic Appeal (Undergraduate)
Completed forms should be returned to MSUM Registrar’s Office, Owens 210, 1104 Seventh
Ave S, Moorhead, MN 56563 or faxed to 218.477.2941 or send to Jill.Helm@mnstate.edu. Please
contact Jill Helm in the Registrar’s Office if you need assistance (477-2521).
INSTRUCTIONS:
Along with this appeal form, a TYPED letter must include the following information:
PART 1) The first line should clearly state your request. If your appeal is to withdraw retroactively from courses, be sure to list the semester,
course title, and instructor(s).
PART 2) Provide a clear and concise explanation of the events, which were beyond your control that led to the need for this appeal. Please limit
your explanation to a paragraph or two.
PART 3) Include supporting documentation, such as, medical documentation, academic advisors and/or employers memos or letters that
support your appeal.
This form is not to be used for Financial Aid-Academic Suspension. Please refer to the Academic Support Center at http://www.mnstate.edu/asc/
This form is not to be used for grade changes. Please refer to the Appeal – Grade Policy at http://www.mnstate.edu/academicaffairs/policies-procedures.aspx
SECTION I:
SECTION II:
SECTION III:
YOU WILL BE NOTIFIED IF A DECISION CANNOT BE RENDERED DUE TO MISSING/INCOMPLETE DOCUMENTATION OR IF FURTHER EXPLANATION
IS REQUIRED. YOU WILL BE CONTACTED THROUGH THE INFORMATION YOU PROVIDED AT THE TOP OF THIS DOCUMENT.
Minnesota State University Moorhead is an equal opportunity educator & employer and is a member of the Minnesota State Colleges & Universities System.
System level appeal. If a student is not satisfied with a college or university transfer academic appeal decision, the student may appeal the decision at the system level to the Senior Vice
Chancellor of Academic and Student Affairs. The decision of the Senior Vice Chancellor shall be binding on all system college and university parties.
❑ WITHDRAWAL; If you are requesting a late withdraw, you must explain clearly why you missed the withdraw
deadline. Except in serious extenuating circumstances, if you have completed the course, or earned a passing grade, your appeal
will be denied. Decisions regarding tuition and/or fee refunds are not determined by this committee.
(Appeals to retroactively
withdraw cannot be accepted if five years have passed since the course in question was taken)
❑ RESIDENCE REQUIREMENTS; 8 of the last 12 credit appeals, must include the list of courses taken at other
institutions. All other residency appeals must clearly explain the residency rule which you are appealing.
❑ OTHER (specify): _________________________________________________________________________________
IF YOUR APPEAL IS BECAUSE OF MEDICAL ISSUES (PHYSICAL OR MENTAL), YOU MUST ATTACH A NOTE FROM YOUR MEDICAL SERVICE
PROVIDER. WITHOUT DOCUMENTATION, YOUR APPEAL WILL BE DENIED. If you have concerns about providing the documentation to a committee, please
speak to Jill Helm (Jill.Helm@mnstate.edu), Owens Hall 210, or 218-477-2521) about providing it confidentially.
Committee Recommendation: ❑ Approval ❑ Denial (insufficient justification for exception) ❑ Tabled
________________________________________________________________________________________________________________
Signature of Committee Chairperson: __________________________________________________ Date:___________________________
Name______________________________________________________________________________ Dragon/Star ID__________________________
Email________________________________________________________________ Anticipated Graduation Semester ________________________
(after the committee meets, their decision will be emailed to you)
Student’s Signature: _______________________________________________________________________ Date: ____________________________
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