Administrative Withdrawal Reinstatement Request Form

For Students Administratively Withdrawn Due to Non-Payment

Student’s              Semester/Year

Name                

               Withdrawal

CWID/ SS#                 Date

Complete this section for Reinstatement within 5 calendar days of administrative withdrawal.

     Course & Number  Section Number  Hours    

_________Reinstate    _______________  _______________  ___________  

     _______________  _______________  ___________  

     _______________  _______________  ___________  

     _______________  _______________  ___________  

     _______________  _______________  ___________  

     _______________  _______________  ___________  

     _______________  _______________  ___________

     _______________  _______________  ___________  

 Student’s Signature __________________________________________________________________Date____________________

 Campus/Site Controller’s Office Representative___________________________________________Date___________________

Complete this section for Reinstatement within 6 to 10 calendar days of administrative withdrawal.

     Course & Number  Section Number  Hours    Instructor’s Signature (Required)

_________Reinstate    _______________  _______________  ___________  ______________________

     _______________  _______________  ___________  ______________________

     _______________  _______________  ___________  ______________________

     _______________  _______________  ___________  ______________________

     _______________  _______________  ___________  ______________________

     _______________  _______________  ___________  ______________________

     _______________  _______________  ___________  ______________________

     _______________  _______________  ___________  ______________________

 Student’s Signature __________________________________________________________________Date____________________

 Campus/Site Controller’s Office Representative___________________________________________Date___________________

Registrar’s Office    Reinstatement Processed on ____________________________________ (Date)

Use Only:    Registrar’s Office Staff: ________________________________________ (Signature)

Form 1412/005 (8/05)

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