NO APPEAL WILL BE ACCEPTED
UNLESS YOU ATTEND A SEMINAR
Name:
Student ID:
Email:
Phone #:
Date:
APPEAL FORM for Disqualified Student
Step 1. Sign up in the counseling center to attend one of the following seminars:
Wed., May 25, 2005
5:00-7:00pm
Admin 9c
Sat., June 11, 2005
10:00am-12:00noon
MQ-5
Wed. June 22, 2005
5:00-7:00pm
Admin 9c (Finals week)
Sat., July 9, 2005
10:00am-12:00noon
MQ-5
Tues., July 12, 2005
3:00-5:00pm
MQ-4
You must sign up for the seminar of your choice at the receptionist’s desk in the Counseling Center prior
to the seminar. Please check our web site for our hours of operation at www.deanza.edu/counseling/.
Step 2. Bring this completed form with you to the seminar you signed up to attend.
If you need help completing this form, make an appointment to see a counselor or walk-in
and wait to see someone in the Counseling Center.
Step 3. Attach a copy of your De Anza academic records. To do this, go to
www.deanza.edu/students/. Then go to “My De Anza” to print out a copy.
1) My goal at De Anza is:
‰ Undecided
‰ AA degree and/or transfer
‰ AA degree only
‰ Certificate
‰ Other. Explain
2) My major is
3) I plan to work _____________hours/week in the Fall 2005 term.
4) English Level
‰ I have completed EWRT 1A or ESL 5 with a grade of “C” or better.
‰ I have not taken the English or ESL placement test.
I have to do the following in order to get into EWRT 1A or ESL 5. Check all that apply:
‰ Take EWRT 100A/150 ‰ Take ESL 134
‰ Take ESL 24
‰ Take EWRT 100B/160 ‰ Take ESL 144
‰ Take ESL 72
‰ Take READ 201/202 ‰ Take ESL 151, 152, 153
‰ Take READ 100/101 ‰ Take ESL 161, 162, 163
rev. 5/05
DQ APPEALS FORM
5) Math Level
‰ I have not taken any math placement tests.
‰ I have taken a math placement test and have placed into
‰ I have completed with a “C” or better the following math course(s):
‰ I plan to repeat the following math course:
6) List what courses you want to take in the Fall 2005 term:
7) Explain why your appeal should be approved. Include special circumstances that
affected your performance, changes that have occurred that will influence your future
performance or other relevant information. If appeal involves medical reasons, please attach
documentation. Attach additional pages if needed.
-- ----------------------------------------------------------------------------------------------------------------------------
Counselor Recommendation:
________GPV
‰ I recommend appeal be approved.
‰ I recommend appeal be denied which means student will not attend Fall 2005 term.
Comments:
Counselor Name
Extension
Date
NO APPEAL WILL BE ACCEPTED UNLESS YOU ATTEND A
SEMINAR!
For Staff Only: (check off when done)
‰ Hold Removed on SIS, if approved
‰ Recorded on Database
rev. 5/05
DQ APPEALS FORM