Office of the Vice Provost
For Undergraduate Education
Application for Readmission
We are pleased to learn of your desire to return to the University. Your application will be carefully considered, and you will be informed of the decision as soon as all materials are received and reviewed.
Be certain to read the attached for important information regarding the readmission process.
PLEASE PRINT CLEARLY
Name: ______
LastFirstMiddle
Former Name (if applicable): ______
LastFirstMiddle
Student ID#: ______
Home phone: (______) ______Cell phone: (______) ______
E-Mail: ______
Permanent Address:
______
StreetCityStateZip
Mailing Address (if different from permanent address):
If readmitted,will this mailing address continue to be in effect?___Yes___No
______
StreetCityStateZip
AnticipatedTerm of Readmission: ___Fall___Winter___Spring___SummerYear______
AnticipatedStatus:___ full-time ___ part-time
Left as: ___ Dismissed ___ Withdrew______
Primary Reason for Withdrawing
Term/Year of Last Attendance:______
Are you an international student? ___Yes___No
Have you been convicted of a felony?___Yes___No
Have you been dismissed from a college for disciplinary reasons?___Yes___No
PLEASE COMPLETE REVERSE
College Study SINCE DEPARTURE from the University
Have you attended any other college(s) since you were last in attendance here? If so, please complete the following, listing all colleges attended whether or not you expect to receive transfer credit. List separately each term of enrollment elsewhere, including Summer Sessions.
College NameTerm EnrolledFT/PT# Credits
Example: SUC BuffaloSpring, 2013FT15
______
______
______
______
You must request the registrar of all institutions attended to immediately forward an official transcript directly to this office.
IF YOUR FILE WILL NEED REVIEW BY THE COMMITTEE ON ACADEMIC STANDING AND YOU ARE CURRENTLY PURSUING COURSEWORK ELSEWHERE, MID-TERM GRADES OR LETTERS FROM PROFESSORS ON DEPARTMENT LETTERHEAD SHOULD ALSO BE SENT TO THIS OFFICE. IT WILL NOT BE POSSIBLE TO TAKE ACTION ON YOUR REQUEST FOR READMISSION UNTIL THESE TRANSCRIPTS/LETTERS HAVE BEEN RECEIVED.
Will you or have you completed an Associate Degree program since you last attended the University?___Yes___No
If Yes,at which college?______
What type of degree? ___AA___AS___AOS___AAS
What major or concentration? ______
MAKING FALSE STATEMENTS AND/OR FILING FORGED DOCUMENTS AND/OR SUBMITTING FALSE MATERIAL TO A UNIVERSITY COMMITTEE VIOLATES THE STANDARDS OF ACADEMIC INTEGRITY. SUCH VIOLATIONS ARE SUBJECT TO APPROPRIATE DISCIPLINARY ACTION.
______
SignatureDate
Send this form to:
Undergraduate Education/Withdrawal and Readmission, LC30
University at Albany
Albany, NY 12222
Phone: (518) 442-5821Fax: (518) 442-4959
I:\Withdrawal and Reentry\RDMAPP.DOC
Updated 9/13/2012