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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For Students Administratively Withdrawn Due to Non-Payment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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