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* First Name: |
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Middle Name: |
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* Last Name: |
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* Date of Birth (00/00/0000): |
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* Student ID: |
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* Street Address: |
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* City: |
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* State: |
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* Zip: |
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* Phone (555-555-5555): |
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* Email: |
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* Do you receive GI Bill benefits: |
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* Drop/Withdrawal Term: |
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View your class schedule in CampusConnection to ensure the following information is complete. Appeals will not be processed if courses are not listed below. |
Action Requesting Definitions
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Appeal Action Requested |
Description |
Grade to W |
Removal of current letter grade and change to Withdrawal with (W) record on transcript |
Grade to No W |
Removal of current letter grade and change to Withdrawal without record on transcript |
W to No W |
Removal of current Withdrawal with (W) record on transcript and change to Withdrawal without record on transcript |
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Course Appeal #1
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* 1) Subject (ex ENGL): |
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* 1) Catalog # (ex 110): |
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* 1) Class # (ex. 10258): |
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* 1) Class Title (ex. College Composition I): |
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* 1) Action Requesting: |
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* 1) Last Date of Attendance: |
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Course Appeal #2
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2) Subject: |
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2) Catalog #: |
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2) Class #: |
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2) Class Title: |
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2) Action Requesting: |
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2) Last Date of Attendance: |
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Course Appeal #3
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3) Subject: |
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3) Catalog #: |
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3) Class #: |
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3) Class Title: |
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3) Action Requesting: |
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3) Last Date of Attendance: |
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Course Appeal #4
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4) Subject: |
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4) Catalog #: |
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4) Class #: |
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4) Class Title: |
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4) Action Requesting: |
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4) Last Date of Attendance: |
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Course Appeal #5
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5) Subject: |
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5) Catalog #: |
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5) Class #: |
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5) Action Requesting: |
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5) Last Date of Attendance: |
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Course Appeal #6
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6) Subject: |
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6) Catalog #: |
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6) Class #: |
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6) Class Title: |
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6) Action Requesting: |
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6) Last Date of Attendance: |
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Course Appeal #7
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7) Subject: |
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7) Catalog #: |
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7) Class #: |
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7) Action Requesting: |
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7) Last Date of Attendance: |
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Course Appeal #8
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8) Subject: |
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8) Catalog #: |
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8) Class #: |
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8) Action Requesting: |
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8) Last Date of Attendance: |
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Course Appeal #9
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9) Subject: |
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9) Catalog #: |
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9) Class #: |
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9) Class Title: |
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9) Action Requesting: |
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9) Last Date of Attendance: |
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Course Appeal #10
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10) Subject: |
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10) Catalog #: |
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10) Class #: |
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10) Class Title: |
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10) Action Requesting: |
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10) Last Date of Attendance: |
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* Appeal Reason/Suggested Documentation: |
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* Explanation for Academic Records Appeal: |
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* I undertand that a denied appeal drop/withdraw application for the current term will be processed as a regular withdraw. All dates and deadlines for a regular withdraw will be followed. |
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* I accept all academic and financial consequences resulting from this appeal. |
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* Signature: I certify to the best of my knowledge that the information on this form is true and complete without evasion or misrepresentation. I understand that if found to be otherwise, it is sufficient cause for rejections or dismissal: |
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Spam Check: 6 + 9 = |
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