Separation Reinstatement Request

Please refer to Policy # 7.013

Banner ID

First Name*

Last Name*

Personal Email Address*

Campus*

Select

Change of Campus*

As part of your reinstatement plan do you anticipate changing campuses?

Select

Degree*

Select or enter value

Program

Select or enter value

Last Term attended

Requested Reinstatement Term*

Select

Reinstatement Statement*

Please provide a brief explanation (250 words or less) of the circumstances leading to separation from PCOM and any contributing factors.

Intervening Steps*

A description (500 words or less) of steps taken during the intervening period to address the reasons for separation, e.g., medical issues, family issues, academic issues.

Reinstatement Plan*

A plan (250 words or less) for success following returning to the program, if granted. On the Separation Reinstatement form, the student may request consideration for a different campus from the original campus if circumstances warrant.

Outside Enrollment*

While you were separated did you attend another institution?

Select or enter value

Transcript

Please include transcripts from any other institution attended while separated.

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