PCOM Student Dismissal Appeal Form

First Name*

Last Name*

Banner ID (900xxxxxx)*

Type of Appeal*

Select or enter value

Email Address*

Campus*

Philadelphia

Georgia

South Georgia

College or School*

College of Osteopathic Medicine

School of Pharmacy

School of Health Sciences

School of Professional and Applied Psychology

Program*

Select

Reason for Appeal*

Procedural Errors- please provide specific policies and/or procedures that were not followed

Perceived Bias- Define the context of the observed bias and provide supporting evidence/examples

Student Attorney

You can later change your answer to this question but you MUST notify the committee when scheduling your appeal hearing.

Select

File Upload*

Please attach your appeal letter and all supporting documentation. Please ensure your appeal letter/documents clearly address the reason(s) you checked above. You can attach multiple files.

Drag and drop files here or