UNIVERSITY OF ILLINOIS AT SPRINGFIELD
Office of Records and Registration Appeal of Academic Suspension
Please complete, print (see "Print Form" button above), acquire the appropriate signatures, and return this form to the Office of Records and
Registration, University Hall, One University Plaza, MS UHB 1076, Springfield, IL 62703-5407. Forms are processed on a weekly basis. Please be
sure to carefully complete all information prior to printing the document.
Last Name First Name
Mailing Address City State
Records (217) 206-6709 Degree Audits (217) 206-8216 Registration (217) 206-6174 Graduation (217) 206-7730
For Office Use Only
Processed By:
Date:
Copies (distributed by the Office of Records and Registration):
Original:
Student
Adviser
I request review of my academic suspension from UIS for the following reasons:
Student Signature
Adviser
Program/Department Representative
Dean/Associate Dean
Date
Date
Date
DenyApprove
DenyApprove
DenyApprove
See Attached Notes
See Attached Notes
See Attached Notes
Check all that apply
Adviser Dean
Date
Approvals
Program
Permanent File
Major
Semester
In addition to my most recent transcript, I am submitting the following documents in support of this appeal:
Dean/Associate Dean signature required to
approve appeal of academic suspension.
Last Semester of Attendance
Prior to Suspension:
Year Semester
Reinstatement
Requested
Year
UIN
Zip Code
Daytime Phone
