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TO: Director of Financial Aid
FROM: ______________________________________________

The student listed below has accumulated an excessive number of absences in the course designated.
This is to recommend that your office so inform the student in order that he/she might take corrective action.

_______________________ _______________________ _______________________
SSN Last Name First Name
_______________________ ______________________________________________
Sort No. Course Name (EX: ENGL  2201, CISM 1101, etc...)
Please check: Regular Term Course
Term A Course
Term B Course
This is a: Day Class
Evening Class
TOTAL NUMBER OF ABSENCES: ______________________________________________
Last date of attendance in the course: ______________________________________________
If corrective action is taken immediately, can work be made up? Yes             No
In your opinion, has the student ceased to actively pursue the course? Yes             No
______________________________________________ _______________________
Instructor’s Signature Date
Forward one copy.    
ROUTING: (1) Financial Aid/Veteran’s Affairs
(2) Counseling Center
(3) Studentís Admission File