Form R-17 - Reinstatement Request Form - Fayetteville Technical Community College
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1Date of Request
Semester & Year (Fall 06)
REINSTATEMENT REQUEST FORM
/
/
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Student ID #
Program Code
Veteran's Benefits:
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YES
NO
Course
Course
Section
Credit
Advisor's Name
Prefix
Number
Number
Hours
LAST:
FIRST:
MI:
Student's Name
LAST:
FIRST:
MI:
Total Credits
I am requesting to be reinstated because
I understand that I am not officially enrolled in this class, even though the instructor allows me to continue to participate in
order to stay current with course work. I further understand that reinstatement is contingent upon approval of this request
and payment of all outstanding debt to Fayetteville Technical Community College. I also understand that if I am required to
pay tuition and fees out of pocket, I have five (5) business days from the date that I have been contacted by personnel
from the Office of Business and Finance to pay the outstanding balance. Failure to pay the outstanding balance by the
deadline will void this reinstatement request.
Student’s Signature
Date
APPROVED
/
DISAPPROVED
( PLEASE CIRCLE ONE )
Comments:
Instructor's Printed Name
Instructor's Signature
Date
APPROVED
/
DISAPPROVED
( PLEASE CIRCLE ONE )
Comments:
Department Chair's Printed Name
Department Chair's Signature
Date
APPROVED
/
DISAPPROVED
( PLEASE CIRCLE ONE )
Comments:
Dean's Printed Name
Dean's Signature
Date
Student Owes:
$
Date Paid:
Comments:
Office of Business & Finance Printed Name
Office of Business & Finance Signature
Date
Action Taken:
Registrar/Assistant Registrar Printed Name
Registrar/Assistant Registrar Signature
Date
FTCC Form R-17
Revised 04/04/2012
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Parent category: Business