Student Appeal
Last Name ____________________________________ First Name ____________________________ Middle Initial ___
Student ID (NSHE ID) # _______________________________ Phone # ________________________________________
Email address (primary email on MyCSN) ________________________________________________________________
Please select one of the options below
Academic Suspension (Completed registration card with a maximum of two courses and Degree Sheet obtained from
appropriate academic counselor/success coach must be attached)
Academic suspension Effective ____________ ________ Requesting to return on ______________ ___________
Semester Year Semester Year
Refund/pardon of fees
• Only classes which have been dropped with or without a grade of “W” can be considered for a refund/pardon of
fees appeal.
• No refund will be made if the Student Appeal Form and supporting documentation are not received by the end
of the semester following the semester being appealed. Exceptions may be made in extraordinary circumstances.
• If approved for refund/pardon of fees, all academic grades will remain on student’s permanent record and will
continue to be used to calculate Excess Credit, Satisfactory Academic Progress Policy (SAPP), Return to Title Four
(R2T4) and any other state or federal mandate.
Please select from the approved criteria below for refund/pardon of fees appeal (for additional information please review
the current CSN catalog). Committee’s decision will be e-mailed to the e-mail address listed on student’s MyCSN account.
Death of immediate family member; with supporting documentation attached
Extended incapacitation or hospitalization of student; with supporting documentation attached
Involuntary job transfer; with valid supporting documentation attached
Late notification of denial to a specific degree program; with supporting documentation attached
Verifiable institutional error by CSN
Student recalled in support of a national emergency in accordance with NSHE policy; with
supporting documentation attached.
Semester _______________ Year __________ Class/es ______________________________________________________
Please explain in detail the circumstances which support your petition pertaining to your request. Please attach additional
explanation if necessary along with required documentation.
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Student Signature Date Submitted
FOR COMMITTEE USE ONLY
COMMENTS:
APPROVED DATE
DENIED DATE
CSN is an Equal Employment Opportunity/Affirmative Action institution and does not discriminate on the basis of sex, age, race, color,
religion, disability, national origin, veteran status, sexual orientation, genetic information, gender identity, or gender expression in the
programs or activities which it operates. For more information, visit http://www.csn.edu/nondiscrimination.
