Dismissal Appeal Form

Note: The information you provide on this form is secured to protect your privacy and confidentiality. This form is submitted directly to Dr. Stuart Brown, Chairperson of the Waterbury Campus Dismissal Committee.

This form must be submitted to the Waterbury Campus Dismissal Committee as soon as possible and no later than January 10, 2008. If there are accompanying documents you may fax them to the committee at 203-236-9805 or you may drop them off in the Student Services suite on the 2nd floor of the Waterbury Campus.

Name:
PeopleSoft ID:
Permanent Address:
       City, State, Zip:
Phone: (example: 555-555-5555)
Email Address: (example: Joe.Husky@uconn.edu)
Current Major:
Previous and/or Future Majors:
Academic Advisor:

Are you currently enrolled in any Summer classes?   Yes  No

If you answered yes above, please enter where you are taking classes:
Please list the intercession courses in which you are enrolled or plan to enroll: 1)
2)
3)
4)
 


Please provide an explanation of the circumstances that contributed to your academic difficulty:

Will you be including documentation via mail, fax, or other means regarding your circumstances (e.g., medical documentation, court records, etc.)? Yes  No
 

Please describe your long-term goals including your academic plans for the next semester and beyond:
 

Note: The information you provide on this form is secured to protect your privacy and confidentiality. This form is submitted directly to Dr. Stuart Brown, Chairperson of the Waterbury Campus Dismissal Committee.