MLT Readmission Form

Health Sciences Division	Apply • Schedule • Register
MLT Request for Readmission

First Name:
Last Name:
Middle Name:
ACC Student ID Number:
Address:
Apt. Number:
City:
State:
Zip:
Phone:
Alternate Phone:
Email:
Date of Withdrawal (semester/year):
Reason for Withdrawal:
Request for readmission to the following course(s):
Requesting readmission for (semester/year):
State your reasons for seeking re-admission:
I understand that I am allowed only one readmission into the MLT Program.
Yes No
I understand that my request for readmission will be ranked according to my priority rating (see MLT student Handbook) then by grade or standing in the course(s) at the time of withdrawal.
Yes No
I understand that the Admissions Committee will either approve or deny my request for readmission based on my past performance in the MLT Program.
Yes No
I understand that if my request for readmission is approved I will be required to repeat all clinical courses.
Yes No
I understand that if my request for readmission is approved, registration in the course(s) is permitted only if space is available.
Yes No
I understand that the deadline for readmission requests are: Spring (January 5th), Fall (June 5th), and Summer (May 5th).
Yes No
I understand that I must contact the MLT Department Chair (223-5932) after the deadline for readmission requests to determine if space is available.
Yes No
When you click submit you will be prompted to print a copy of this for your records. Please do so.