1. Administrative Withdrawal Reinstatement Request Form
      1. For Students Administratively Withdrawn Due to Non-Payment
      2. Student’s       Semester/Year
      3. Name         
      4.         Withdrawal
      5. CWID/ SS#          Date

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For Students Administratively Withdrawn Due to Non-Payment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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