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 Judy DiLaurenzio, Assistant Dean of Students.

This form must be submitted to the Torrington Campus Dismissal Committee as soon as possible and no later than TBA. If there are accompanying documents you may fax them to the committee at 860-626-6844 or you may drop them off in the Student Services.

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 Judy DiLaurenzio, Chairperson of the Torrington Campus Dismissal Committee.