Academic Separation Appeal Form
Student Services Office | 309.341.5237 | khand@sandburg.edu
This form is used to appeal your academic separation from Sandburg. If you need to appeal for financial aid, please use this form: https://sandburg.jotform.com/210686294933868
Name
*
First Name
Last Name
Email
*
example@example.com
Student ID#
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Semester you would like to return to Sandburg:
*
What is your current degree or certificate objective?
*
Please provide a detailed response to the questions below.
1. What extenuating circumstances prevented you from succeeding while you were previously enrolled at Sandburg? Documentation supporting your appeal is recommended (examples: a letter confirming medical treatment, a death certificate for an immediate family member, etc.). Please attach these documents using the file uploader below.
*
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2. What changes or improvements have you made that will help you succeed academically when you return to Sandburg? Please provide a detailed explanation.
*
I certify the information provided above is true and complete.
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Signature
*
Date
*
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Month
-
Day
Year
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