Academic Appeal Form

* Please complete all required information before submitting form:

Name: *

Address: *

Phone Number: *

E-Mail Address *

Student I.D. *

Date of Dismissal (MM/DD/YYYY): *

Division: * Undergraduate Graduate

Undergraduate: *

Traditional Transfer Accelerated

Graduate: *

Program: *

Courses Failed: *

Course Number *

Course Name * Professor

Is this your first appeal for dismissal? * Yes No

If No, when was your last appeal? (MM/DD/YYYY) *

Please use the text box below to write your statement or copy and paste your letter in the text box to the Academic Appeals Committee formally requesting an appeal of your dismissal. It should contain reasons for course failures resulting in dismissal in as much detail as possible. It should also contain a statement about how you would plan to ensure your success in your studies if your appeal were to be granted. You may also include any other explanatory information that you believe will assist the committee in considering your appeal. Click the Submit button to send this form to Nursing Appeals@SHU.