Fillable Appeal Request Form This form can only be (University of Houston-Downtown)

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Appeal Request Form This form can only be (University of Houston-Downtown)

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The Appeal Request Form This form can only be (University of Houston-Downtown) form is 1 page long and contains:

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Appeal Request Form
This form can only be submitted
electronically via email
A. Student Information:
UHD ID Number Term/Year
First Name Last Name
E-mail Address Telephone
B. Select appropriate box and reason below; please carefully make your selection.
6 Course
Drop Limit
Excess Fee Charges
Select reason below
Extenuating Circumstances
Drop/Withdrawal Request
Select reason below
Bacterial Meningitis Vaccination
BMV Non-compliance Drop
Class Attendance
Please read the
important 6 Drop
information included
on Page 2 of this
form.
18 Developmental
Hrs.
Medical Reason
Other________________________________
Over Degree Hrs.
Military Deployment
3
rd
Course Repeat
Other Reason ____________
C. Please explain your request/appeal in detail below, explaining the extenuating circumstances regarding your appeal.
If more space is needed, attach additional sheet.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
State your request: ___________________________________________________________________________
D. Were you awarded Financial Aid for this term? Yes No (if Yes, verify the impact of this request on your Financial Aid)
Are you requesting to drop ALL your classes for this term? Yes No (if Yes, the 6 Drop limit does not apply)
E. List Classes and CRNs to be Dropped or Added (if any). If more space is needed, attach additional sheet.
SUBJ/NUMBER
CRN
LAST DAY YOU
ATTENDED THIS CLASS
REASON FOR DROP or ADD
F. Mark this box to confirm that you have attached supporting documentation as part of this appeal request. An incomplete appeal request form or a
form submitted without supporting documentation will not be accepted or reviewed. Supporting documentation includes but is not limited to: doctor’s
statement, hospital bill, death certificate, police or insurance report, obituaries, funeral notices, newspaper article, instructor or advisor correspondence.
STUDENT SIGNATURE ______________________________________ DATE _______ / _______ / __________
For Office Use Only:
Resolution Notes Received By ____________ Date __________
Processed By ____________ Date __________
One Main Street, Ste N330 ph: 713-221-8999
Houston, TX 77002 fax: 713-223-7450
_________________________________________________________________________________________________
Administrative Drop
Revised: 09/2014
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Appeal Request Form This form can only be (University of Houston-Downtown)

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Completed 28 January 2021

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