Appeal Request form

Student first and last name *

A Number *

Net ID *

Date You Withdrew *

I Am Submitting an Appeal for... *

Medical Reasons (Physical or Mental)

Compassionate Reasons

Please provide a description of your appeal request. *

Reason	Documentation Needed
Medical (self)	Letter from attending physician or a licensed counselor (if mental)
Compassionate: Care of Seriously Ill Family Member	Letter from attending physician about family member
Compassionate: Death in Immediate Family	Letter from physician or official announcement
Compassionate: Military Duty	Copy of military activation orders
Compassionate: Unanticipated Financial Hardship	Relevant documentation to support appeal

Please upload supporting documentation based off the above chart. *

If you happen to see this, do not fill this field.