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 Christine Mosman.

This form must be submitted to the Torrington Director of Student Services as soon as possible and no later than Thursday, June 13, 2013. If there are accompanying documents you may fax them to 860-626-6844 or you may drop them off in the Student Affairs Office (Room 118) on the Torrington 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:


Please list the intersession 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 Christine Mosman, member of the Torrington Campus Dismissal Committee.