Academic Dismissal Petition

Students who have been academically dismissed from Augustana University may petition to have their dismissal reversed. In addition to the completion of this form, you will be asked to receive the written support of an Augustana faculty member or advisor. This form must be received at least 30 days prior to the start of the term for which you request to resume studies at Augustana. Please note that your petition will not be reviewed if you have an outstanding balance due at Augustana.

Personal Information:

First Name

Middle Name

Last Name

Birthdate

Mailing Address

Country

Street

City

Region

Postal Code

Email Address

Phone Number

Social Security Number

Augustana ID Number

Academic Information:

Do you plan to return as a Full-Time or Part-Time student?

When would you like to resume your studies?

Intended academic major(s):

Previous Dates of Attendance at Augustana:

Have you attended any other post-secondary institution (college, university, vocational, or trade school) since your last date of attendance at Augustana?

Indicate the name of your preferred academic advisor. (If a preferred advisor is not indicated, an academic advisor will be assigned to you in your area of study).

If yes, please indicate which college or university you have attended since leaving Augustana University.

If you have been away from Augustana for at least one term, please share what you have been doing since your departure.
Include any school or work experiences.

Please share what you believe to be the factors that led to your academic dismissal from Augustana.

Please identify what has changed since your dismissal that allow you to achieve success if you are reinstated.
What specific support plan and/or services do you intend to utilize to help you find academic success here?

Do you plan to live in on-campus housing?

Will you be applying for need-based financial aid by completing the Free Application for Federal Student Aid (FAFSA)? Augustana’s FAFSA Code is 003458.

In order to be considered for readmission to Augustana, you must provide a letter of support from a current Augustana faculty or staff member. Please upload that letter of support here.

I hereby affirm that the information provided is correct, complete, and honestly presented.

Sign Initials

Augustana is committed to providing equal opportunities for access to and participation in its programs and services, without regard to sex, sexual orientation, race, color, religion, creed, national origin, ancestry, age, or disability.