Appeal for Benchmark Failure

If you choose to file an appeal, this form must be submitted within 5 business days
from the date you received the notification email.

Last Name:	First Name:
UID Number:
Phone Number:	(please include area code)
UM E-mail:
Major:
Primary/Dept Advisor:	Phone:

The date I was notified of the decision:

Indicate the BENCHMARK you did not meet:

Students must submit a typed description of the extenuating circumstances that lead to this appeal, as well as justification and a plan for the future (use the box below)

I will be submitting additional supporting documentation such as medical letters, transcripts, etc.
to: Appeals Committee.

Office Use Only:

Appeal approved:_______ Appeal denied: ________

Signature:________________________ Date:__________

Notes: ______________________________________________________________________________

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